2014_0813_RPZ (6) CgiECK �NE:
IRRIGATION DOMESTIC �C FIRELINE
BACI�LOW PREYENTION ASSEMBLY TEST AND MAINTENANCE REppRT
NAME OF PWS: G N � `/ D� �;o P�E L L,
PWS I.D. #
LOCATION OF SERVICE: 7 7 S l�� �G,,� r,�� f�P 2 D_�10° �So� q
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
[� Reduced Pmsure Principle o Pressvre Vacu�Breaker _
� Double Chxk Valve ❑ Atmosphere Vacuum Breaker
Manufact�er t�q T i S Siu 3�`� ,.
Model N�ber L F o 0 9 r�3 Located At ���c H A�� ��L 2 or��v�
Seriai Ni�ber 2- �Z 0`1
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubl�Check Valve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Valve
Inirial Test DGClosed Closed Ti;ht Opened at Opened at _nsid
Ti�t Leal:ed o 3,`� nsid _osid
RP-�psid �,(�
Leal:cd o Did not Open o Leal;ed o
�P�
and
Materials
Used
Test After DC-Closed Closod Tight o Opened at Opeaed at nsid
Repair Tight 0 nsid _nsid
RP sid �
The above is certifiod to be tcue.
Firm Name ��'fl A�r��C I�.��u.��D� Certifiod Testc ��n.�5 t a�t�e ie., �rt�F�r�D
Firm Address 1 u I� L r w►�Y 0�. '�`�03 Cert. Testa No. �D 0 l 3 3 D lP Date �' �3'I�
G .�+►2dLo(.L i vns, 'Tj� 7�00'] L��`�r`J.
�
Gauge # 0 4�,0�{DS�3
llate last accuracy tested i I- I 1 -I 3
White- Customer's Copy Yellow - City Copy Pink- Tester's Copy