2015-0310 C�IEC� ONE:
IRRIGATION� DOMES�"IC FIRELINE �
S,�C�'i.OW PREVENTION ASSENIBLY TEST AND MAINTENANCE REPOR?
NAME OF PWS: �i�T°l L� l" L r-(�� 1 t
PWS I.D. �
LOCATION OF SERVICE: � 3 5 F+t= Q�'-f�
Tl�e backf7a«• pre��entic�t� assc,mbly d�tailed belo�t�has been t�.st�d and maintained as required by TGEQ
rc�ul�tic�ns and i� certitied to be operatin�w•ithin acceptable paran�etzrs.
TYPE OF ASSEMBLY
c Reduc:d Pressure Principle ❑ Pressure Vacui�Breakcr
�.'J Double Chexk Vaive ❑ Aunasphere Vacuum Breakcr
Ma�nufacturer �c T�S Size v
Model Number 77`� X Located At l�co c �
s������ 1 d a H 7 3
REDUCED PRESSURE PRINCIPLE:�.SSEMBLY PRESSURE V�CUIJM BREA�R
�
Double Ch�cic 4 alve Assemblv
Ist Cherl� 2nd Checi: Reiief Valve �1ir Tnlet Check Valve
iuinal Test DC-Closed Closed Ti;ht ❑ Opene�ai Clpened at osid
Ti�i ` ❑ Leal:ed � nsid osid
���'� RP-�psid
Leai�:ed � � Did nat Open ❑ Leal:ed ❑
��
and
Matcsials
Used
Tcst After DC-Closed Closed Tight o Ogened at Opcncd at _nsid
Rcpair Tight o _ vsid osid
RP sid
The above is cer�fied to be true. �-C�
Firm Name tLC�v.� ��°' Catified Tatc �b�C<<�� I�elen ri-- _
Firm Address 1'� ��� ?ci `� Cat Tester No. /'���`�d� Date c� �7/',
fn1�� %�
�`i811g� # [,�Q�i c� �v
Date last accucacy tested_ '3�/j
White - Customer's Copy Yellow - City Cogy Pink -Tester's Copy