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2015_0310 (7) ' C�IECK �NE: ' IRRIGATION DOMESTIC FIRELINE� � �� ' BACI�'LQW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPORT' '' NAME OF FWS: ��T`I C> � C�r��1/ PWS I.D. # �t' �-� ' LOCATION OF SERVICE: `�� i t�a� �� c� ' Thc back{lo�� prevention as�emhly detailed below has been tested and maintained as required by TCEQ ' regul��lions and is certitied to t�e operating within acceptable parameters. TYPE OF ASSEMBLY '', ❑ Rcduc,�Pressure Principle � Pressure Vacu�Breaker ', 6�j Double Check Valve ❑ Aunosphere Vacuum Breal:er ' Manufacturcr �11�T`TS Siu ��'i ' Model Number CX}`7 w1 �- Locaud At �•� Lt�;��• ' Scrial Nimmbcr � �`18(a ' REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R Doub[e Check Valve Assembty lst Check Znd C3eci: Relief Valve Air Inlet Chec3c Valve '' Inival Test DGClosed Closed Ti;hs �' Opmc�at Opened at nsid ', T'i�t �' a i4 L�al:ed �ol ❑ nsid usid ', �Ic h�7 RP-_„_psid ' LeaI;ed o Did not Opea D Leal:ed o RePau�s ', and Materials ' Used Test Aftu DGClased Closod Tight o ppeaed at Opened at _nsid ' Repair Tight ❑ nsid osid R.P sid The abovt is certified to be uua. y�� Firm Name�e.r�� ,_f z Certified Testc ��e�K� L�/�r,v�ei- Fum Address �v��c �`l� G��x�„�� Cat Testa Na �>c��i Date ��/a 1�� Gauge # �?�j v��;'a��c� llate last accuracy tested 3�� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy