2013_0621 (2)CHECK ONE:
Ill.ltst:,ATION DOMESTIC FIRELINE
BACK -FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
PIA'S 1.D,
LOCI-'.70N OF SER`riCE: /11
T1;, h;tck II(-.v I,ivv c ntIon t, ,emhI\ detailed tic Iwy hay hecn ;and maintained as required by TCEQ
mid is -ei't k2d left he orer�ltln- ti'1t}1111 ilccq t,
TYPE OF ASSEMBLY
Reduced Pressure Principle Z, Pressure Vacum Breaker
Double Check Valve Atmosphere Vacuum Breaker
Manufacturer wo 7.15 Size %Q
Model Number ! `I Located At we'iT- i%x, . T- O%J i � �d py � � � �� w•
Serial Number 10 -,� 15'(--
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B9-alve
ji
rDoubie Check- Valve Assembly
j Ist Cheer 2nd Check- Relief Valve
Air inlet
Check Valve
! initial Test
DC- Closed
Tiht 3. � �
Closed Tint
C ,n
Leaked
Opened at
Opened at
�'
psid
psid
RP -____ —psid
Leaked G
�
Did not Open O
Leaked
Repaus
1
I
j
11and
MIaterials I€
Used
!
4
Test After
DC- Closed
CIosed Tight a
Opened at
Opened at
psid
Repair
Tight c ►
�Dsid
psid
RP Sid
The above is cemlLed to be true.
Firm Name A r -10,,J -c-
Firm Address ft2 6,Q,e -7 s ]
t'4T GX'c vi c-'• -C y , e
Gauge # 12 `3 :2d
Cat Tester No. 04n'cl- /cL Date .1?/ / // 3
Date last accuracy testedl /3 —
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy