2015-0908 (3) CFIECK �NE:
IitRIGATION llOMESTIC � FIRELINE
BACKFLOW PREYENTION ASSEMBLY TEST AND MAINTENANCE REP4RT
NAMEQFPWS: �-���`l C� � L�'��rll
PWS I.D. #
LOCATION OF SEFZVICE: "I� �Y2Q C�D►'�-�` Pkl��
The backl7c���� prevention assen�bly detailed belo��-has been tcstcd and maintained as required by TCEQ
r�`Tulatic�ns and is certitiect to be operatin�*«�it}�in acceptable p��rameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principlc � Pressure Vaeu�Breaker
� Double Ghcck Valve c Atmasphcre Vacuum Breaker
rZ rr
Manufacnue: �tlA-E-�-5 Sizc
Model Nimmber �0�7�'i/ Loeaud At S� � -�-CIr
Serial N�ber tA�V-2u(�a��R
REDUCED PRESSURE PRINCIPLE ASSE?YiBLY I PRESSURE VACUIJM BREAI�R
Double Chetk Valve Assembly
lst C3ecl: ?ad Chec1: Reiie{Valve �ir Inlet Checic Vaive
Inival Tcst DC-Closed Closed Ti�t p� Opened at Opeaed at nsid
Ti�t �-� 1� Lcal:cd ❑ nsid osid
RP-�_,psid 1 � �{
Leai;cd a Did not Opea � Leal:e� ❑
g�� �
and
Mataials
Uscd
Test Ai3er DC-Closed Closed Tight o Opened at Opcatd at nsid
Rtpair Tight o nsid nsid
RP sid
The above is certified to be true.
Firm Name ��'��� ��r.2 I�oS Certified Tessca �_X.�San 1-1vSTan
Firm Address ��� 7q� Cert.Testa No.� �1 b(��� Date 1 1�� I 5
u�aXa►�a Ch�e �u
cauge # _O lv I j C�C�7�
liate last accuracy tested j
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy