2014_0424 (2)CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE Jd' � �/ fit 3 3
I
BAC�LOW PREVENTION ASSEMBLY TEST" AND CE REPORT
NAA� OF PWS: L / T � G'' F - (c� ��J r_!/
PWS LD. #
LOCATION OF SERVICE: �3d(j /� i L/ � e �>
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Rtduced Pztssune Principle Q Pressure Vacvtms weaker
�7 Double Check Valve � Atmosphac Vaeuimm Breaker
Manufacttacr I.Jc �'r y
Model Plumber Uc�'� 0+'1 .�
Serial Nvmber O � '�� � `i
Si zt •� /'�
Located At Ucl u c r / ✓► ti � H T
P,.J� s � � . d -c
The above is certified to be true. '�,� 5
Firm Name .�/ T•e, � r�. �e
Firm Addsess Qc. �� x 7 r 7 Wa �. ' ��°
�511oti?
Certified Tester iJalcJy :.mac G✓t• v� n � �
Cent Tester No. ["��n �s �/ d s' Dam `l / ay � ��f
Gauge # � �G�_4 JO /u
Date last accuracy tested '3 /i��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRIl�lCTPLE ASSE1�iBLY PRESSURE VACITiJM B R��R
Double Check Valve Asse�
1st Checlt
2nd ChecL
Relief Valve Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed TiP, o
Opened at Opened at
nsi
Tigbt �
Leaked o
n sid n sid
3�/ 7 f � `'�
12P -_paid
Leaked o
Did not Open o
r r�ti� o
Repairs
and
Materials
V V1 1 i
/�
� ��� 1'c��'
Yv� lnn �'Po L,,,, <
Used
Test ARer
DC- Closed
Closed Tight k!
Opined at Opened at
o sd
Repair
Tigblt �7t ,� d7
�,�
n sid n sid
RP
The above is certified to be true. '�,� 5
Firm Name .�/ T•e, � r�. �e
Firm Addsess Qc. �� x 7 r 7 Wa �. ' ��°
�511oti?
Certified Tester iJalcJy :.mac G✓t• v� n � �
Cent Tester No. ["��n �s �/ d s' Dam `l / ay � ��f
Gauge # � �G�_4 JO /u
Date last accuracy tested '3 /i��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy