2015_0310 c�iEc,� ux�:
�, IARIGATION DOMESTIC � FIRELINE
I BACT�LOW PREYENT'ION ASSEMBLY TEST AND MAINTENANCE REPORT
I NAME4FPWS: �-r�T`� C' (-' Lc�(-�Art/
'� PWS I.D. # \_�c)�-�_
� LOCATION OF SERVICE: `"��'v ��J:c��.� c�
I, Thc backfilo��� prevention asse�nbly detailed belo��� has been testcd and maintained as required by TCEQ
�' regulations and is ccrtitied to be operating within acceptable parameters.
, TYPE OF ASSEMBLY
�� ❑ Reduce�Pressure Principle ❑ Pressure Vacu�mm Breaker
' �1 Double Check Valve ❑ Aauosphae Vacuum Breal:a
,,
' Manufact�er ��� �' � S Siu O�
Model N�ber (701 wl '� Located At �Q i`� �,��� � �,v1 c i��
s��t N�b� A �t l� v�
� �•
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V4CUiJM BREAI�R
Doub(e Cherk�%aive Assembly
lst Check 2nd Chec{: Relief Valve :�ir Initt Check VaIve
! Initial Test DC-Closed Closed Ti;ht ❑ Opeaai at Opened at �id
t���f� Ti�t I� Leal:ed -_�' nsid __nsid
RP- l v ._,nsid /�'
� f%��R� Lcaked O Did not Opea o Leal:ed ❑
�� �� �a
', and
I, Materials C l�c��(
'� Used
Test Afrtr DC-Closed Closed T'ight � Opeaod at Opmod at osid
' �pau ?i�,ht (��' � r,j�v _ �sid osid
II Yc �S RP sid
II�'�, The above is certifiai to be true, y'��
I Firm Name 4 C �'���a �;�� CertiSod?es[ez i-.�G�-�vr� i�G+�v�z.r
I Firm Address Q� �a o 1 Cat Testa No. �J"S°l.��` Date � `f , �
I P�Cwc. �^�+ lY ���y'�
I�',, Gauge # �3 q���r7�c�'
III, llate last accuracy tested 3���
I�� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy