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2015_0310 (9) C�IECi� I.INE: IftRIGATION llOMESTIC FIREI.INE � yVle:�h �„�,� BACI{F'LOW PREVENTION ASSEMBLY TES'T AND MAINTENANCE REPORT NAIv� OFPWS: ��?� G� � Lr�l��-�/ PWS I.D. # eJ�-� LOCATION OF SERVICE: ``�� Thc backtlow ��revention assembly detailed belo�� has been tested and maintained as required t�y TCEQ rebulations and is certiticd to be operating within acceptable parameters. TYPE OF ASSEMBLY ❑ Reducad Fr�ssure Principle ❑ Pressure Vacu�Breaker y�i Double Check Valve +QG b�1 ❑ Aanosphere Vacuum Breal:er Manufactaaer IlJc,fi�'� Siu � a Modei Ntmibcr �7�"i �t� Locaud At /l�Q T� �J c-v� � scrial N�ber �U f1 a f `3!10 7 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACIJUM BRE.4I�R Double Check Valve Asstmbty lst Check 2nd Checl: Relief Valve Air Ialet Checic Valve Iniaal Test DGClosed Closed Ti,�ht t9 Opened at Opened at osid Ti�t, 5� Q6' Leal:ed ❑ _nsid nsid p�54 �-_�_`_.ps�a �.� Lcal:cd ❑ Did not Open o Leal:ed o Repairs and Matcrials Used Test ARer DC-Closed Closed Tight o pp��at Opcaod at asid Repair Tight ❑ _osid osid RP sid The above is certified to be true. y�S Fum Name�r�•s-^ r�'� Certifiod Testa �U�1�-�v►c I�'�c?r v��F Firm Address pc� �ac�ic 791 iA►9c,�„►.��-�- Cert.Testa No. Gc`�c,5'l�5 D� '��1�j GBUgB # (1'3�(:ec�c�,a�Cr llate last accuracy tested ��r�� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy