2015_0310 (2) I!� C�IECK ONE:
I�, IHRIGATION�� DOMESTIC FIRELINfi
II'', BACKF'LOW PREYENTION ASSEMBLY TEST AND MAINI'ENANCE REPORT
�I NAMEOFPWS: �-r��`� G� �' Lr_�n���l
�i, PWS I.D. # 1J c�► l'-�
I LOCATION OF 5ERVICE: �[3e� `-�+� �� �� �
II The h��cktYo�� preventian assembly detailed belo«� has been te�ted and maintained as required by TCEQ
I i-egulati�ns and is certified lo be operating wit}iin acceptable parameters.
�i TYPE OF ASSEMBLY
�'i ❑ Reduc�d Pressure Principle ❑ Pressure Vacu�Breaker
I � Double Chcck Valvc ❑ Atmosphere Vacuum Breal:er
''� Manufacturer G��e.�5 Size o�',
I�� Model Nt�ber ��`7 wt� Locaud At ��✓1 5 T t c.�- '�� ��.�rc—
II J7 � � �G>�a l(�cx � 1 J (i�^-JL"T
I $CI131 TilmmbCf
�I REDUCED PRESSURE PRINCIP'LE ASSEMBLY PRESSiTRE VACITUM BREAKER
�, Double Check v alve Assambly
' lst Check Znd Checl: Relief Valve Air Inlet Check Valve
I!, Iaitial Test DGClosed Closed Ti;ht o Opened at Opened at nsid
I Ti�t �•J � Leal:ed ,� psid nsid
'',� � �,, � RP-_gsid
, LcaI;ed o � Did not Opea o Leal;ed ❑
I RePair�
, and
'', Mataials
I Used
I� fiest ARer DGClosed Closcd Tight C] Opened at Opeaod at �nsid
'', R�pair Tight o _ �sid nsid
II RP sid
The above is ccrtifiod to be wt. y��
'I, Fum Name �C�'��4� ����- Certified Tester �tJe.�„��. L✓r.�n�•—
I, Firm Address Q��t 7`�� I�Q n��►� Cert. Tester No. ��c»4'�l�S Date K c� r5
I�', (�auge # !'��7�.�r3�'�
!, ll�te last accuracy tested ���
�� White - Customer's Copy Yellow - City Copy Pink -Tester's Copy