2015-0301 CHECK �NE:
IRRIGATIiDN llOMESTIC FIRELINE �
BACI{F'LOW PREVENTION ASSEMBLY TEST AND MAIN'TENANCE REPORT
NAAIv�OF PWS: L��?`I G'� � L r,(-�p�1l
PWS I.D. #
LOCATION OF SERVICE: _�'��� s ���Y�e-'� '
T}�ie backflc��� ��revention assembly detailed below has been tested and maint�ined as required by TCEQ
re�ul�ti�ns and is certiti�d to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Frinciple o Pressure Vacu�Breaker
� Double Gheck Valvc ❑ Amnospher�Vacuum Breal:er
Maaufacturcr ((��r 7 � � Size �
Modei':v�ber � 7 `/ X Lcjcated At t,��cy e_ �
Scrial N�ber �C9F� �� 3
REDUCED PRESSL)RE PRINCIPLE ASSEMBLY PRESSURE V�CUIJM BRE.4I�R
Double Check�alve Assembly
lst Checi: Znd Checl: Relief�alve Air Inlet Check Valve
Ininal Test DGCloscd Closed Ti;ht ❑ Opened at Opened ac �sid
��/7%/� Ti�t ❑ Leal:ed ;�j asid _nsid
RP- •�nsid
r`',,$� LcaI:cd rI� � Did not Open ❑ L,ea1:e� o
�� � ( �
and a
Materials � ���iC
Uscd �- I�c�i�
Test Af3er DGClosed Closed Tight J� Opeaed at Opeaod at ��sid
air Tighc �.� I� 3.p �nsid nsia
cs s RP sid
The above is certifiod to be�u. +�-�S
Fum Name .d r T�c�-�. �' � Certifiod Testa GJo��rt i�:✓��� _-�
Fum Address pd �x 7r,� Cert Testa Na. �,�����/� � Date �'/�i/�S�
lLcxc� �nrcw.= ; � 7g ��,y
Gauge # �3 v a,�,)1;�'
llate last accurecy tested ���j
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy