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2012_1108 (2)
4 WESTERN STATES FIRE PROTECTION BUILDING INSPECTIONS BACK FLOW PREVENTION ASSEMBLY TEST Name of PWS s rhXf�s PWS ID # i Address of Service Permit Number — Name of Irrigation Company or Installer V3 Zs 01� Company Address A) iV4m cr iA-,r1 t � "!f j A-4 -l'.P Phone � `r' �! 7c City — 0,,091 -u State r9(, Zip 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 iL Double Check Valve Manufacturer W *� Model Number Serial Number I Ii[�/j Pressure Vacuum Breaker Atmosphere Vacuum Breaker t/ Size Specific Use Zit''a CERTIFIED TESTER INFORMATION Firm Name WWs tk iy S' is rinj ^olea,2 a Phone SL14 63V t") O ► � i L CityVn Address _PA *11111 State r� Zip 7 4� Certified Tester # Hno I ©w Certification Expires R ` 15 TVA� AV" 162 Tester Name (PLEASE PRINT) jetMerSignature Date Tested Reduced Pressure Principle Assem ly Pressure Vacuum Breaker Double Check Valve Assembly Air Inlet Check Valve First Check 3 Second Check ;t . t' Relief Valve Opened at PSID ❑ Failed to Open PSID ❑ Leaked Initial Test f 2 - DC Closed Tight ❑ Leaked 51 Closed Tight ❑ Leaked 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 WWs tk iy S' is rinj ^olea,2 a Phone SL14 63V t") O ► � i L CityVn Address _PA *11111 State r� Zip 7 4� Certified Tester # Hno I ©w Certification Expires R ` 15 TVA� AV" 162 Tester Name (PLEASE PRINT) jetMerSignature Date Tested