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2015_0708 , . , _ �� . /� � C�IECK ONE: ; IRRIGATION ' DOMESTIC v' FIBELINE �� '� w �,.,,� BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR? �rv�` NAME OF PWS: .�,n,�/ P1 r� �'�I .'�,� ��, �'C�i o a� 1,�.��-�' PWS I.D.# r LOCATION OF SERVICE: 1 Z�1 f�r s� � ��� `--�; 'Ibe bac�low prcvmtion asscmbly detailod below has beea tested aad maintained as required bv TNRCC regulanons aad is cerdficd to be operating withia acceptable parameters. TYPE OF ASSEMBLY � Redueed Pressure Principle ❑ Pressure Vacuum Breaker o Double Chxk Valve o Atmosphere Vacuum Breaker Maaufacturer (a.,J1��-t S Siu � 1�z Model Ivumber � � I1'� � Located At � - ����� (� 1 'j �-r G Serial Nimnber T��D �— -. REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BRF.AKER �- Daubie Check Vaive Assembly �� .��: lst Check 2nd Checl: Relief Valve 4ir Inlet Check Valve Inival Test DC-Closed . Closed Ti;ht ❑ Opeae�at Opened at nsid � Ti�t � Leal:ed o � .U psid __osid � RP-�,��psid �, L,eal;od o Did not Open o L.ralced o �P� aad Materials Used Test After DGClosed Closed Tight o Opened at Opcaai at ___nsid Repair Tight o �sid osid RP sid The above is certified to be true. , Firm Na�����17_"_N.I�, �� I� Certifis�Testa Firm Address O � �,',r. Cat Taster No. Date _1���:�- � �,.o� Gauge # ��'r�f'�OC� , � � ��:. �. � � � llate last accuracy tested �' White- Customer's Copy Yellow - City Copy Pink-Tester's Copy