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2015_0310 (6)
' C�IECK ONE: ' IRRIGATION DOMESTIC FIRELINE � ��,�n [� n� ' BAC'KFT.OW PREVENT'IUN ASSEMBLY TEST AND MAINTENANCE REPORT ,, NAMEOFPWS: L��?�� � r ['c�(-�p��/ ' PWS I.D. # ' LOCATION OF SERVICE: �00 �I��d�l'IGI, ' The backtlow prevention assembly detailed below has been testcd and maintained as required by TCEQ '� rebulcit�i�ns and is c�rtified to be operating within acceptable parameters. ' TYPE OF ASSEMBLY , ❑ Ruiucad Pr�ssure Priaciple ❑ Prassure Vacu�Breaker ', S� Double Chxk Valve Q��� 0 Aunosphere Vacuum BreaLer ' Manufactt�cr IAe���'"� � Siu 1 d� ' Model N�ber 7 7'� i�C p,� Located At -5 L� 'l�c v i' '' Scrial Nimmber I Uc���c� ' REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CULJM BREAKER ' Double Chetk Valve Assembly lst Checl: 2nd Checl: Retief Valve :+ir Ialet Checic Valve ' Inival Test DC-Closed Closed Ti�ht ,�; Opened at Opened at _nsid ' QC-55 Ti�t _3_� � Leal:ed y.e) ❑ nsid nsid RP-_psid ', Leai;ed o Did not Opea D L,eal:ed ❑ RePairs ', and Materials ' Used ' Test Ai3er DGClosed Closed Tight 0 Opeaod at Opeaed at nsid , Repair Tight o osid __osid ' RP sid The above is cutified to be tru�. v c� Fum Name t��'7tu�1 F'��� Certifiad Tata 1-J i�,lc,.�µz. �i.l�,.,�,�� ', PirmAddress �� a��X 7�11 i���hc.�K�� Cert 1'estaNa t�o�9t1�� Date `�1c-� / � ' Gauge # Q=�c>,�•�c� �� ' llate last accuracy tested ��/�� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy