2015_0714 (3) �
C�IBCK ONB:
IRRIGATION DOMESTIC V FIRELINE
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BACIQ�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENqNC�REppRT
NAMEOFPWS: �P��'�I 1'"tiq � �G�'`�U�
PWS I.D. #
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LOCATION OF SER�JICE: � s • �•�Q P
The bacl�low preveatioa assembly detailod below has beea tested and maintaiaed as nquired b�, 'TNRCC
reguladons aad is oectified to be operating withia acceptable parameters.
TYPE OF ASS�LY
. � Reduced Pressure Principle o Pressure Vacuum Breaker
❑ Double Chxk Valve o Atmosphere Vacuum Breaker
Maaufact�aer ���"S Size � ,►
Modei Ivumber � V� �►'�r Located At ��5� �e ZZ
Saial N�bcr ��7� �/
REDUCED PRESSURE PRINC'�LE ASSEMBLY PRESSURE VACUUM BREAKER
��` Doubk Check Valve Assembly
.* �
lst Check 2nd Checl: Relief Vaive 4ir Inlet Check Valve
InidaI Test DC-Closed Closed Ti�ht o Opea�d at Opened at nsid
Ti�i ❑ Leal:ed � ���'/ nsid nsid -�
�GS s ��.�S�a o -` _`
Did not Open o L,eaked o
�P�
and
Materials
Used
Test Af�er DGClosed Closcd Tight O Openod at Opea�d at _�sid
Repair Tight ❑ _�nsid _osid
RP sid
The above is certified to be true.
Firm Name`-��,D� � ��J...V Catified Testa �<-n u �C� � I �
Firm Address ��� �J�Ci `�,r' Ccrt. Tester No.!-��`�`���U Date � ��
�` `� c8� � �Z-5 c�00
.�_ .
llate last accuracy tested � �j ��
White-Customer's Copy Yellow - City Copy . Pink-Tester's Copy
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