2014_1008 C�IBCK ONE: �
IRRIGATION ✓ DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEN�LY TEST AND MAINTENANCE REPOR?
NAME OF PWS: l�"1 �P�'�l �- � �U �p m�I�
PWS I.D.#
LOCATION OF SERVICE: ��� �CJJ �''I
The bacl�Iow preveation assembly detailed below has been tested and maintained as required by TNRCC
re�ons aad is certi5ed to be operating withia acccptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacu�Breaktr
t� Double Check Valve ❑ Atmosphere Vacuum Breaktr
��/
Maaufacttaer ��' C-+C� Size
Modei Number o � � Located At �r'Dt'1�' �� � � �
s«��rr��a � D� 3?�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubte Check Valve Assembly
lst Check ��Z 2nd Checl:�.� Relief Valve 4ir Inlet Check V�lve
Initial Test DC-Closed Closed Tight `�t Opeaed at Opened at �sid
Ti�t 1$ Lcal:ed � osid _osid
�a��7 RP-ipsid
L,e a l;e d o D i d not O pea o L e a l:e d ❑
�P�
and
Materials
Used
Test After DGClosed Closed Tight o Opened at Opcaed at _nsid
Repair Tie,,ht � _�sid osid
RP sid
The above is caertifiod to be true.
Firm Name � E'�I �'�� Cerafi�Teste �a V t� � t l'�-1
\
Firm AddrGss ��� �� � '� Cert.Taster No. ����Date �� � �7
Ga� � Z�Sao
llate last accuracy tested g ��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy