2015_0304 C�IECK f�NE:
IRRIGATION DOMESTIC FIRELINE ib yvlr� � L � � t
BACKFT..OW PREVENTIQN ASSEMBLY TEST AND MAINTENANCE REPOR'T
NAME OF PWS: L��?`l G� F� �r�(-�A r /
PWS I.D. �
LOCATION OF SERVTCE: �� � ���t< ��
The backflo��� prevenlion assembly detailed belc�w has been testcd and maintained as required by TCEQ
re�ulations and is certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduc�Pressvre Principle � Pressure Vacutmm Breaker
� vc C A�osphae Vacuum Breaktr
� �' �
Maaufacmrer 6+ia.T�5 Siu
Model N�bcr "��7`� �[ nA Locat�d At ��3 � �'�-' i T
Scria!ivimzbcr �(�� ��'f�
REDUCED PRESSURE PRINCIPI.E ASSEMBLY PRESSURE V�CUUM BREAI�R
Doublt Cbec�c Vajve Assembly
lst Check 2ad Checl: R��{Valve Air Inlet Chedc Va1vt
Inival Test DC-Closed Closed Ti�ht � Opened at Opened at osid
Ti�t ��� � Loal:ed �.� ❑ nsid nsid
'?j(f{��7 RP_ osid
L,eal:ed o I?id nat Qpea 0 I,eal:ed ❑
�P�
and
Materials
Used
Test Aftet DC-Closed Closed Tie�t o OQmed at Opeatd at nsid
�
R�tpair Tight � _�nsid __,nsid
RP sid
The above is certified ta be�ve. y� 5 ^
Firm Name,��Cl Vl r i �`� CQ uliQl 1 C$iQ' ^�W L N w'L �p.)'! �n h O,�
Firm Addirss �� �,�` �7`i l Cert Testar No. �'c�l'/�� Date ��tl I�s
(�c.Xc.v�� �KL 'rY >jI6'�
Gauge # p=3C>>'',� I�'
llate last accuracy tested �/�•�
White- Customer's Copy Yellow - City Copy Pink- Tester's Copy
c�i�cx uxE:
IRRIGATION�_ DOMESTIC FIRELINE
BACKFT,OW PREYENTION ASSEMBLY TEST AND ' CE REPOR?
NAME OF PWS: [;�?�/ d � l c>�A r�/
PWS I.D. �
LOCATION OF SERVTCE: ��'� G� �7��� t (2�
The backflaw prevention assembly detai led below has been tested and tnaintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Rtduc�Pressure Principle ❑ Pressurc Vacutmm Brcaker
� Doublc Chcck VaIvc c Atmosphae Vacuum Breaker
Maaufacttaer �'z�e c•' Size d� .�
Modei N�bcr U>>�' Located At �� v C�::�
�LM�T�' /l���rc T i cu T
Scrial Number � � ��G'�`�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double C3eck�%alve Assembly
lst Checl: 2nd Checl: Relief Valve Air Inl�t Chedc Valve
Iniaal Tesi DC-Closed Closed Ti�t � dpened at Opened at nsid
Ti�i �•� � Lcal:ed .�.,�, ❑ �sid osid
"31�'/� R.P-_,psid —�
Lealced o Did noc Opm o Ltal;ed 0
��
and
Mauerials
Used
Test After DGClosed Closed Tight o Opeae�at Opeaed at _�sid
Rtpair Tight 0 __,osid osid
R.P id
The above is certifiefl to be tnu. �O Y 5
FIIIII N�IG�L T�� � �'``� CCR�C�IGS�C �W8•�v�� W C N N�r
Fum Addnss �� ��o�� � `1 � Cat Tester No. C>C�c�3•I J`i � 'S `�/�i�
(;,,'�x c..� ..,-t. T r "���c;5
Gauge # �i.3 Ci�� .7.� 1�
llate last accuracy tested 3%���
White— Customer's Copy Yellow — City Copy Pink—Tester's Copy
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE �j i5 / �c ��
BAC'I�'LOW PREYENTI�N ASSEMBLY TEST AND MAINTENANCE REPORT
NAMEOFPWS: L��?`l G'' F� �'ca�A�-�/
PWS I.D. #
LOCATION OF SERVICE: �7t'� � ���'1'�kr t Q
The backflo���prevention assembly detailed below has been testcd and rnaintained as required by TCEQ
regulations and is certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduc�Pressure Principle O Pressurc Vac�Breaker
i�r pouble Check Vaiv� G Atmosphere Vacut�Breala
Maaufact�er I%J�7�� Size 3 l�1
Modei Nt�ber ��'7 Located At ����' � i�'�� � �'
Scrial Numbcr c: ;�. Kcsa�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubte Check Vaive Assembly
lst C3ecl: 2nd Checi: Relief Valve Air Inlet Chedc Valve
Inival Test DC-Closed Closed Ti;ht � Opeaed at Opeaed at nsid
Ti�t (- � � Leal:ed �,�, 0 osid nsid
3���)�7 RP• osid �
Leai:ed o Did nat Open 0 Lpl:ed o
Repairs
and
Materials
Usod
Test After DGClosed Closed Tie,�t ❑ Opeaed at Opeaed at _�sid
Rcpair Tighi o _nsid osid
RP sid
The above is cxrtifiai to be tive. il-e �
Firm Namr ,�C r�.r► �'`�= Cetifiod Test� �1.�c.ti v�� i�.�c�,..n=�
Fum Address ��� J��x '7�i `1 Cat Testa No. P�r�n�'��J� Date 3/•i 1�g
�,.�Q XG h� L H t T 1° 7 j f(�j"
�iaUge # 1��C%.�9':J�� i �
llate last accuracy tested 3��r 1
White- Customer's Copy Yellow - City Copy Pink - Tester's Copy
C�IECK C�NE:
IRRIGATION DOMESTIC � FIRELINE
BAC�L,OW PREVENTION ASSEIV�LY TEST AND MAINTENANCE REppR?
NAMEOFPWS: ���?`l G� � Cra�prll
PWS I.D. �
LOCATION OF SERVICE: �7c:�v i�� • �c i 1�i� l R �
The backflaw prevention assembly detailed below has been tested and maintained as required by TCEQ
re�7ulations and is certitied to be operating ���ithin acceptable parameters.
TYPE OF ASSEMBLY
❑ Rcduc�Press�urc Principle ❑ Pressure Vacuimm Breaker
� Double Check Valve ❑ Aanosphae Vacuum Breaka
i'
Maaufact�er Ill�'� T� 5 Size �
Model Iv�ber (.�'`7� ` Located At L inn�T�' �c.'�!,c T %r.� v c�,�;,�
Serial Number I L' �c7 1 e�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V:�CUUM BREA,KER
Double Check Vaive Ass�mbly
lst Checl: 3nd Checi: Relief Vatve Air Inl�t Chedc Valve
Iaival Test DC-Closed Closed Ti;ht � dpened at Opeaed at nsid
Ti�t f,�, � Leal:td r � o �sid nsid
3��1�i7 �--.�s�a -`
Lealced o Did not Opm O Leal:ed 0
�P�
and
Maurials
Uscd
Test After DC-Closed Closod Tight ❑ Opened at Opeaed at _�sid
R�epair Tight o _��sid nsid
RP id
The above is artified to be tive. �.��j
Fum Name�ri��w �.•-E Certifiai Testc �43c��c. i,�.�e ti y,�
Firm Address Pc^� �=a�c 7� 1 Cat Teste No. �'?c%c. �r�1 J 5 Dati �`I��J
�lvj�XCv.cC�- T�` '75'/bi
GSLge � O 3 C��:�:�i c�
llate last accuracy tested �/i rl
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy