2015_0310 (4) �!, C�IECK I�NE:
I'i IRRIGATION �( _ llOMESTIC FIRELINE
III BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
I�, NAME OF PWS: L��?`l �' � L�c,(-�p r 11
��I PWS I.D.# I.J cJ � �
I!� LOCATION OF SERVICE: ''��J W Z�f�Cs�?� a
Tl�c backflc�w �revention asseinbly detaile�i below has been tested and maintained as required by TCEQ
j regulacic�►1s and is eertified to b� aperating within acceptable parameTers.
I, TYPE OF ASSEMBLY
'� ❑ Reducrd Pressvre Principle ❑ Prossure Vacu�mm Breaker
II � Double Chxk Valve o Atmosphere Vacuum Breaker
�I Manufacturer LN'�T"c� S ize �
�, Modei Number U�"7�► 1 Located At r"��.� STr=-�3' � M�'r�•
�! Strial N�bcr r� c� �v j?HO
I�� REDUCED PRESSURE PRINCTPLE ASSEMBLY PRESSURE VACUITM BREAKER
I�!, Double Check Valve Assembly
Ilst Checl: Znd ChecR Reiief Valve Air Inlet Checic Valve
�', Inival Test DGClosed Closed 7i�ht ❑ 4pene�at Opened at nsid
' Ti�t ❑ Leakcd ❑ osid _nsid
�! ���``i RP-s„psid
I Lcal;od o Did not Opm 0 Leaked 0
II �� /I�Cd �CeT� TG 'IYY�e c'7�r � � i � ��efleti
; and
I MaLeriaLs G't-,.� y��'i Tt�� c r ' � S "?►��
�, Usai
I Test ARer DGClosed Closed Tight o ppeaed at Opeaod at osid
' Rtpair Tie,ht D nsid osid
i, R.P sid
�', The above is catifiod to be�ve. �'-� s
I�I, Fum Name ,4.r�/c v� �•'� Ccrtified Ttster l--�fr�eT+�= W c��•2-
I'�, FirmAddress t'� �c+X� 7�77 �1v��ne��-•- CatTestallo. 4"�t�b9Ll�� Date ��� I/S
I��I, Gauge # C�3e��3� i�
III, llate last accuracy tested 5�/5
II! White - Customer's Copy Yellow - City Copy Pink -Tester's Copy