2015_0714 (4) C�IBCK ON$: � �
IRRIGATION DOMESTIC ✓ FIRELINE
� .
��' BACI�LOW PREVENTION ASSEIV�LY T`EST AND MAINTENANCE REPORT
NAME OF PWS: �l�D,P�I —= `J D � �I S
PWS I.D.# �
LOCATION OF SERVICE: f � e k.J�.°.S� G�r/C�WQ
T'he bacl�low prevention asscmbly detailed below has bxn tested aad maintaine� as required by TNRCC
regulacions and is cerdfied to be operating withia acceptable parameters.
TYPE OF ASSIIv�LY
- � Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Br�eeaL-et
� i�
Manufacturer �i�� �E'Y1� Size �G Z
Model Number ��� Located At �� ��'��`
Sezial N�ber �� 1 � !
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
�� ,
Doubie Check Valve Assembly
lst Check 2nd Checl: Re]ief Valve Air Inlet Check Valve
IniaaI Test DC-Closed Closed Ti;ht o Opeaed at Opeaed at esid
Ti ❑ Leal:ed o ��sid __,�sid
R.P�sid
L.eal:ed ❑ Did not Open O L,e�alce� o
�P�
and
Materials
Usod
Test Aft,er DC-Closed Closed Ti,ht o Opened at Opeaed at _nsid
Repair Ti,�ht o _nsid _nsid
RP sid
'Ibe above is ccrtifiod to be true.
. �l (�
Firm Name��D e I ( i S� Catified Testa DC�u� 4� '.-�2 t �
Firm Addrzss ��(���ra r►' Cert Testa No. Q�bro� Date'��
;�
- Gauge # ��'SdDU
llate last accuracy tested � � �`�
White- Customer's Copy Yellow - City Copy , Pink-Tester's Copy
�