2015_0310 (5) '� C�IECK t]NE:
I, IRRIGATION�_ llOMESTIC FIRELINE
', BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
�II NAMEOFPWS: ���?`I C' � Lr����1I
II PWS I.D. # �U��
I LOCATION OF SERVICE: "��� �� J.� t� �
�'� ?l�c backflo���prevention assembly detailed below has been te�ted and maintained as required by TCEQ
�i rebulalions and is certifi�ci ta be operating within acceptable p�arameters.
' TYPE OF ASSEMBLY
', ❑ Reduced Pressurc Principle o Pr�ssure Vacu�Breaker
'� y3� Double Check Valve ❑ Amnosphera Vacuum Breaker
'�, Maaufacturcr IA1�Y"'r 5 S iu �:,
II Model Number �'7w1 � Locaud At e�1� ST�`==-` ��? dV)e-Tcl�
II� Scrial N�ber f�r��L'-�c�
II! REDUCED PRESSURE PRINCTPLE ASSEMBLY PRESSURE VACUUM BREAI�R
� Double Check Va1ve Assembly
lst Checic ?nd Checl: Relief valve :�ir Inlet Check Va1ve
I Ininal Test DC-Closcd Closed Ti;ht ❑ Opeaed at Opened at nsid
'� Ti�t � Lea�:ed ❑ nsid _osid
'' ��,`+i RP-_psid
Lcal;ed ❑ Did not Opea o Leal:ed ❑
'�'' Repairs .al?t� ryJ�•'t'�:` TZ� '`Tb►z, r.�cr �, r c. �v i r�e�
'� and
', Mataials L G.� V� 1" Tr 5; c � Th t g T v�,z
' Used
' Test After DGCloscd Closed Tight o Opcnod at Opeaod at _nsid
' Repair Tight o nsid nsid
'' RP sid
'', The above is certifiod to be�ve. v-c f
'' Fum Name Ae T� ��i f C CecCifiod Tester �W c�+v�� i�,,s e.�►v�a'
' Firm Address Pc� �ox 7�i7 i,c.�a�c.�.�-- Cert Tester No. f7C�L>cK�3 ti Date `� � �!
', Gauge # (�3v���1 ��'
', llate Last accurecy tested ���j
' White— Customer's Copy Yellow — City Copy Pink—Tester's Copy