2015_0714 C�ISCK ONE:
IRRIGATION DOMESTIC � FIRELINE
�S
�`.-�� BACICF'I.OW PREYENTION ASSF�NIBLY TE5T AND MAINI'EN.�iCE RLrppRT
NAME OF PWS: C o{�p�� I `� !`9 �.,, '��' GI�o0 1
PWS I.D. #
LOCATION OF SERVICE: � �� � ' Pd����'�`"I
13e bacl�low preveation asse,mbly detailed below has been tested and maintaiae� as requirr,d by TNRCC
reguladons and is cud5ed to bc operating within acceptable parameters.
TYPE QF ASSEMBLY
� Reduced Pressure Principle o Pressure Vacu�Breaker
❑ Double Check Valve o Atmosphere Vacuum Brea�er
Maaufacarer ���1"�` 5 Siu �f`�
Modei Number _�b� �i Located At �`''�St ��ZZ-
Serial Niauber ��'� C.�b�v
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUIVI BREAI�R
�`� Doubie Check Valve Assembly
.,�
lst Check 2nd Checl: �Ef Valv� 4ir Inlet Check Valve
Initial Test DC-Closed Closed Tight ❑ �eae�d at Opened at _�sid
Ti � Leal:ed � �4sid __�osid
���j� R.P�_ '�,psid
�►� c Did aot Opcn o Leaked o
�P�
aad
Materials
Used
Test ARrer DC-Closed Closed Tight o Opeaed at Opeaed at _�sid
Repair Tight ❑ _nsid _�4sid
RP sid
The above is certificd to be true.
Firm Name ��T�e� t L S� Certifi�d Testa I��V�e) Bc�i l e�
Firm Address���� �+'°1�q!�r. Cat TGsta No.��°���Date �� ���
�"`�`� Gauge # �`�' �OOC7
� �� � � � / �{
llate last accuracy tested i
White-Customer's Copy Yellow - City Copy Pink-Tester's Copy
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