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2015_0310 (8)
� CFIECi� ONE: IRRIGATION DOMESTIC FIRELINE� ���55 BACI{F'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT' NAlvi�OF PWS: L 1�?`l G� � ['r-�(�p�t/ PWS I.D. # �v f�� LOCATION OF SERVICE: �-1 c�U ��J b G'��+d The backflow prevention ass�mbly detailed belo�v has been t�sted ar�d maintained as required by TCEQ � re�ulat�ic�ns t3t�d is certit3cd t�o be operating �rithin acceptab]e parameters. TYPE OF ASSEMBLY Q Reduced Pressure Principle ❑ Pressure Vacuimm Breaker � Doublc Chxk Valve ❑ Atmospherc Vacuum BreaL-er Manufacturcr W� �� � g� !3/°1 Model'vtmnber C?G►`� ►v� 1 LocaudAt 111�.��T'� �/c,��. � Scrial N�bcr � ��`3� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE v�CUITM BREAKER Double Check�alve Assembly lst Check �nd Checl: Relief Valve :�ir Inlet Check Vatve Ininal Test DGClosed Closed Ti�t �' Opened at Ogeaed at nsid TiQht 'a c� P.� Leal:td�.� ❑ nsid osid ' �c. �; RP-_,Psid Lcaked ❑ Did not Opea o L,aalxd ❑ RePaus and Materials Used Test ARcr DGClosed Clased Tight ❑ Opeaed at Opcned at nsid Rcpair Tight ❑ _ �sid osid R.P sid The above is cctified to bt true. �-e 5 Fum Name ,1�T��.�� (���� Certified Tester t-�W�'-�•�►.c W t•�.Y►�-� Firm Address �c��p� �7�i 7 1�1c,��,e�� Cert. Tester No. L�c�D 9�1 d"� Date `��r��1� Gauge # O�t��5'Jt� ��' ' llate last accuracy tested 3�/j White - Customer's Copy Yellow - City Copy Pink-Tester's Copy