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2015_0310 (11) C�IECK +DN�: IRRIGATION� llOMESTIC FIRELINE BAC'I�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: _ ���?`l C' r L�c� -,��t 1 PWS I.D.# �c� �� LOCATIOI�OF SERVICE: `'��v �►�1� r,nc� The backflo��v prevention assei��bly detailed below has been t�sted ai�d maintained as required by TCEQ rebulal�ions ��nd is eertified tn he operating witl�in aceeptabl�parameters. TYPE�F ASSEMBLY Q Reduced Pressure Principle ❑ Pressure Vacu�Breaker 1@� Double Check Vatve ❑ Aunosphtre Vacuum Breaker Manufact�cr I��3�5 Size r� '� Model N�ber oo�+� I Located At �4'► S 7 f=-_�o G ;�Vt c.i�� s��N�b� .�a G� 3� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACLTUM BREAKER ����' Doubie Chetk�alve Assembly lst Checl: 2nd Checl: Reiief Valve �1ir Inlet Check Valve Inival Test DGCIosed Closed Ti�t fd� Opened at Openod at nsid Ti�t �. �� ¢� Leal:ed i � ❑ _nsid _osid RP-„psid � Leaked ❑ Did aot Opea o Leal:ed o �P� and Matesials Used Test AR,er DGClosed Closod Tight o ppeaed at Opeaad at nsid Kepair Tight ❑ osid nsid R.P sid 7he above is certifiod to be true. y�a�, Fum Name ��tG� ��-" Certifiod Ttsta 1�(�►1��c,. bt1��n�►t r Ficm Addtess pu aa;� `7`%� i�G x:e v�.e-��— Cert. Testet No. t? )g�i�ti Date r�� -� Gauge # Q�c�F��t h llate last accuracy tested '.7//� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy