2012_11084 WESTERN STATES FIRE PROTECTION
BUILDING INSPECTIONS
BACK FLOW PREVENTION ASSEMBLY TEST
Name of PWS PWS ID #
Address of Service S o iL LN co ` Permit Number —
Name of Irrigation Company or Installer LV--S f
Company Address X -S I% Wa!•NAJQh 71' '44 �' Phone ST3 C1a7&
City — PAAr f State —4—, Zip `7S'0&
The backflow prevention assembly detailed has been tested and maintained as required by TCEQ regulations
and is certified to be operating within acceptable parameter.
Reduced Pressure Principal
_04- Double Check Valve
Manufacturer
Model Number
Serial Number 30535
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
c/
Size Ar
Specific Use FW t jj, ✓ 44OLr
CERTIFIED TESTER INFORMATION
Firm Name kt"N J&" FI n k �� ��tC � �' Phone q 0 7 %SAC
Address a��Y S Lt1 l'lJ d Y' f �1 e n 'D411' % City Co
A4 PA4rl '1 State rot Zip 7sPsa
Certified Tester #
_rb.rn1� 'N12t1S
Tester Name (PLEASE PRINT) ter Signature
Certification Expires R ` 4. 15
Date Tested
Reduced Pressure Principle Assern ly
Pressure Vacuum Breaker
Double Check Valve
Assembly
Air Inlet
Check Valve
First Check `
Second Check
Relief Valve
Opened at
PSID
Initial Test
'
C2,
PSID
❑ Failed to
Open
❑ Leaked
DC Closed Tight
❑ Leaked
Closed Tight
❑ Leaked
ene
Opened at
p
PSID
Repairs and
Material List
Test After Repair
DC Closed
Opened at
Opened at
❑ Tight
❑ Closed Tight
PSID
PSID
PSID
RP PSID
CERTIFIED TESTER INFORMATION
Firm Name kt"N J&" FI n k �� ��tC � �' Phone q 0 7 %SAC
Address a��Y S Lt1 l'lJ d Y' f �1 e n 'D411' % City Co
A4 PA4rl '1 State rot Zip 7sPsa
Certified Tester #
_rb.rn1� 'N12t1S
Tester Name (PLEASE PRINT) ter Signature
Certification Expires R ` 4. 15
Date Tested