2015-0908 CFIECK UNE:
IRRIGATI�N DOMESTIC FIRELINE �
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT
NAMEOFPWS: �1�7� C� � Lc,(}P�1�
PWS I.D. TM
LOCATION OF SER.VICE; Q� �r.e¢r�or-l- Pk y
Thc backllo��� preventioi� ass�:mbly detailed belo�� ha�heen tcsted and maintained as required by TCEQ
t-c��ulations and is certiticd to be operating �<<ithin acceptabl�parameters.
TYPE OF ASSEMBLY
❑ Rcduc�Pressure Principle ^ Pressure Vacu�Breakcr
,� Double Chccl:Valve � Atmosph�rc Vacuum Breaker
Manufacn.u�e: �-{�CI�5�1.f Size 8��
Model N�bcr ,�,QA Locatcd At IUW �Y-e�U'/�'
scrial N�ba q�OCo 0.33
REDUCED PRESSURE PRINCIPLE ASSE:I�LY I PRESSURE VACiJCJM BREAKER
Double Checic Valve Assembly
lst Checi: Znd Chect: Relie{Valv� Air Inlet Check Vaive
Inival Tat DGClosad Clos«i Ti�ht � Opcned at Opencd at nsid
Ti�t 2•�'j �, Lcal:cd � nsid �sid
RP-�,j7sid 3�G
Leai;ed c Did noc Open o L,eal:ed 0
��
and
Mataials
Used
Tcst ARer DC-Closed Closed Tight o ppened at Opeaed at nsid
Repair Tight o nsid nsid
R.P sid
The above is certi6e�to be t�ve.
Firm Name �(''�101�1 ��r.2 1'�DS Cutified Testa IX.tSa�n i-tLSTcn
Ferm Addrass ��� 7�� Cert.Testa No.�Oc�l bC��l Dnte � c S
U�aXa h a C��2 �X
(�auge # O Cv(�C�C7l7�
llate last accuracy tested ,j
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy