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2015_0310 (10)
CFIEC:�K ONE: IRRIGATION�i DOMESTIC FIRELINE BACI{F'LOW PREYENTION AS5EMBLY TES'T AND MAINTENANCE REPORT NAMEOFPWS: �1�7`L G� F� Lc�,-���/ PWS I.D. # �c�1�� LOCATION OF SERVICE: `f�� Q,� � d�� c� Thc hackilo�i� prevention assei��bly detailed belo�v has been tested and inaintained as required by TCEQ re��ulations and is certitied to be operating �vithin acceptable parameters. TYPE OF ASSEMBLY ❑ Reduc�d Pressure Principle O Pr�Ssure Vacue�Breaket � Double Check Valve ❑ Aunosphae Vacuum Breal:er „ Maaufacrurcr �tiG i�S Siu c'� Model Number C�C7"7 IM 1 Locaud Ai Nor� �S i�L � �Jv�c?'�' Scrial Ni�ber ����c�� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BRF.AKER Double Check�alve Assembly lst Checi: 2nd Checl: Relief Valve :,ir Inlet Check Valve Inidal Test DGClosed Clos«i Ti;ht �' Opcue�at Opened at nsid Ti�t � Leal:ed ❑ psid _nsid pcyS RP- ��d sid �7.C� I,eaj;ed o Did noc Open � Leal:ed ❑ �P� and Materials Used Tcst ARer DGCloscd Closed Tight o Qpeae�d at Ogoaod at nsid Repair Tight � osid osid RP sid The above is cerafiod to be truc. y�5 Fitm Name ,�°T��� G y� � __ Certifiod 7uter bJ�,��t (ti r�,.�-E� Firm Address ��'J QQx 7`i7 ��►a.,�...-.- Cert.Testa No. t?CYa�`f�7 Date � `� � r� Gauge # p..3���a f f� llate last accuracy tested '3�/j� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy