2013_0621 (5)CIlt d; 0NL-
I RIC ATIOil- — DOMESTIC FIRELINE )d
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
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LOCATION OF SER` ICE: /` it S yG L
1 il4 Ir.tck Ilow I)I'cv enti�m a� cmi�l� detailyd f�cla�r h��� hecn t�,t�(I :Ind maintained as required by TCEQ
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Reduced Pressure Prrincipie
X Double Check Valve
Manufacturer " 1- r 5
Model Number !:� -___? 04 1
Serial Number `l '3 c I- `f
TYPE OF ASSEINML`r"
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size -3/,l
Located At 0. S L L) ,,<, , } /U . t-) r PC) :M i PC.--, u1
i
{ REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
�
j
j Relief Valve
Air Inlet
Check Valve
Ist Check
2nd Check
initial Test
11 DC- Closed
C10Sed TiahL 101
Opened at
Opened at
nstd
Tilt "0.0
Leaked ❑
nsid
nSid
R- p•_,psid
� G
Leaked
Did not Open ❑
Leaked D
R.-:)airs
and
i
Matcnals
j
Used
f
Test After
DC- Closed I
Closed Tight O
Opened at
Opened at
nsid
Repair I
Tight ❑ (
_ nsid
nSid
w
RP sid !
The above ' certifie d to be true. l e 5
Firm Name A T-fo,/ . -G-
Firm Address P ,x :2 S
Gauge 4
Date last accuracy tested
Catifie d Testa L oc y K e LJ .z vi VI, e"'..
Cem Tester No. Qars( ;, /.,) i ` Date c �r d izz
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
1