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2015-0908 (2)
C�IECK ONE: IHRIGATION llOhiESTIC FIRELINE X BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAMEQFPWS: ���?� C� � Lr- (}��[i PWS I.D. # LOCATION OF SERVICE: Q� �r.2e r�or-l- Pkt,���► Thc backtlo�l�pre��tntion assemhly detailed belo��� has l�een tc�tcd and�naintained as required by TCEQ r-e��ulati��ns and is certiti�d to be operating u�ithin acce�tablc:parameters. TYPE OF ASSEMBLY c Reducrd Pressure Princrole � Pressure Vacuum Breaker `�YY Double Chxk Valvc C A�osphere Vacuum Breaker Manufacnuc: �pV�Y u Sizc 3`�'y Modcl'_viunbcr �C Located At /V�+� �i v-e VGa-�— Scrial N�bcr ���22-( REDUCED PRESSURE PRP.�ICIPLE:�.SSE:�ffiLY PRESSURE VACUUM BREAKER Double Checic�alve Assembly lst Checl: 2nd Chec1: Reli�f Valve :�ir Inlet Check Valve Iniaal Test DGClosed Closed Tight }� Opcned at Opeaed at nsid Ti�t ��(� .�` Leal:ad � � ❑ nsid osid RP-�psid Leai:ed o Did not Opea o L.eal:ed a �P� and Mata-ials Uscd Test ARcr DGClosed Closed Tia.,,ht o Opcncd at 4peaed at nsid Rtp3ir Tight a osid nsid R.P sid The above is certi6ed to be tnu. Firm Name �('`�-I ONl ��r �DS Ccrtified Testa �O�l� t1C;SToYI F�aaa� �(�� 7�� Cat Testa No.aPooi d�5� Dac� 10�� �1S �c�x�►�a Ch� Tu Gauge # D�o���7� llate last accuracy tested j White - Customer's Copy Yellow - City Copy Pink-Tester's Copy