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2015_0113 CIIECK ONE: IRRIGATION DOMESTIC � FIRELINE BACKFLOW PREVENTIUN ASSEMBLY TEST AND MAINTENANCE REpORT � NAME OF PWS: Cf��11 �X PWS I.D. # (��,SS ns�l2,�,�,�,,,li: 4 LOCATION OF SERVICE: �`� E • ��►y 1'�,I � �� C�cl► rX. �5�1 y The backflow prevent�on assembly detailed below has been tested and i�aintained as required by TCEO s-egulations and is certified to be operating �vithin acceptable parameters. TYPE OF ASSEMBLY �t Reduced Pzessure Principie ❑ Pressur�Vacuimi�reaker � Double Check Valve C Amoosphere Vacuum Breal:er Manufact�er iN1`��ns Siu � j�l � Modellv�ber �' � S �'� Locatedqt W��er ��yr« Uc�P� s��N�b� ��t��5 6 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSL'RE VAC[JUM BREAKER Double Check Valve Assembly Ist Checl: 2nd Chec1: Relief Valve A�r Inlet Check Va1ve Ininal Tcst DGClosed Closed Ti;ht � Opened at Opeaed at _nsid Ti�t �' Lcal:ed ❑ �_psid __nsid pti s� �-�S�a �o �� Did not Oprn ❑ Leal;ed o �P� and Mataials Uscd Test After DGClosed Closed Tight ❑ Opened at Opcnod at osid Rcpair Tight ❑ nsid nsid RP sid The above is catified to be uuc. Firm Namc 1�� e�� Certifiod Tesca �h l�'4 N G��n Fum Addrzss �S`�$ N�a�' a�4 U;Pw �n• Cert Testa No. �Po�(l�(r 1 Date �� 3- rs �{. wGr41,��s�/Y (�auge # 0 Sr��6l S llate last accuracy tested l�_ro- �y INhite - Customer's Copy Yellow - City Copy Pink - Tester's Copy I