2015-0629 (4) CIIECK ONE:
IRRIGATION llOMESTIC FIRELINE_�_
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ����, �'��' ���o�/f
PWS I.D. # �g�;.� ���'c. �-�3
LOCATION OF SERVICE: 7dS s,l ��✓�r..J �� i�
The backflow pre��ention assembly detailed below has been tested and maintained as required by TCEO
regulations ���d is certitied to be operaling within acceptable parai�ieters.
TYPE OF ASSEMBLY
o Reducrd Pressure Principle ❑ Pressure Vacu�Breakcr
�, Dc�uble Chxk Val�e G Atmosphere Vacuum Breal:er
Manufactiaer �/!'!�'S S ize
3 �
Model Iv�ber ��1� �� L,ocatod At l�Sc�r ��+-`
Scrial N�ber l��— C'��o S'
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSL'RE VACUUM BREAKER
Doubie Check Valve Assembly
lst C3ecl: 2nd Checl: Relief Valve �►ir Iniet Check Vaive
Ininal Test DGClosed Closed Ti�t ,�- Opened at Opcaed at nsid
Ti�t � Lcal:cd 3. Z � psid osid
� = RP-3`8 Dsid
Leai:ed o Did not Oprn � I,eaj;ed ❑
�P�
and
Materials
Uscd
Tcst After DGClosed C1Qsed Tight ❑ Opene�at Opmod at osid
Rcpair Tight o nsid osid
RP sid
The above is certified to be true.
Firm Name �1 ���3� Catified Testa�°���1_St.�rv�C
����,�, ��� Y.��a
Firm Addr�ss ���,,� �' �6 Z�y Cac. Tena Nar�,r�x�is??�3 Dace�� �
Gauge # �(�►�l��J
llate last accuracy �ested �{ Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy