2015_0310 (3) II, C,�IECiK UNE:
li IRRIGATION DOMESTIC j!� FIRELINE
II BACKFLOW PREVENTlON ASSEMBLY T AND
, TES MAINTENANCE REPORT
��li NAME OF PWS: L r�7;� G'� � L�c����11
�I PWS I.D. # �J�'�
II LOCATION OF SERVICE: LI dc� �,� z d c.� d
��I Thc backtlo��r �revention a�sembly detailed below has been tc�ted ai�d maint�ined as required by TCEQ
j rc�ulatic�ns ai�ld is certificd to be operating w�tl�in acceptable parameters.
��, TYPE OF ASSEMBLY
�', ❑ Reduced Pressure Principle ❑ Pr�ssure Vacu�Breaker
i� �' Double Checi:Valve ❑ Amnosphere Vacuum Breal:er
I Manufactzucr (A:���5 Size �
�li Modei Number C�O`�w� a Locaud At /l1��� 3 � 1 c � ,yv�,��-�
��'�, Scrial N�bcr ���i 6 c)�
II REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRE.�R
�, Double Chetk Valve Assembly
lst Cfieck 2ad Ch�cl: Relief Valve Air Inlet Check Valve
II� Iainal Test DC-Closad Closed Ti?ht ❑ Opened at Opcned at osid
' Ti�t t.� �f Leal:cd !� psid nsid
I�', �c��-� RP-epsid �
i Lcai;ed o Did not Open O Leal:ed o
I�� Rtpairs
I and
, Mausials
i, Used
�'�, Test After DGClosod Closed I'ight o Opeaed at Opcned at �nsid
�I Repair Tight o vsid nsid
I RP sid
I��, The above is catifiod to be truc. y��
II Firm Namc�e Tra� �'��'`t- Certifiod Testa `�W�-t�t I;J��n v,Q�
', Firm Addcrss t'c���x �]�i 1 Ld�,�o►��-- Cert Testa No. fav c�9�ia� Date `�/�1��
�i� C�auge # _Q�c>��3r�� � �
��,, llate last accuracy tested 3�e j
I'� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy