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2015-0908 (4)
CftECK ONE: IRRIGATION llObiESTIC x FIRELINE BACI�'LOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPOR? NAME4FPWS: ���?� C> F' Lc�(}���i PWS I.D. # LOCATION OF SERVICE: Q� �Y.P,Q l�Or-I- P�tu�y The backflora�pre��ention assembly detailed belo�� has heen tcstcd and maintained as required by TCEQ reg���lations atld is certiticd to be operating���ithin acceptabl� parai��eters. TYPE OF ASSEMBLY ❑ Rtduc,�d Pressure Princinle � Pr�ssure Vacu�Breaker � Double Check Valve � Atmospherc Vacuum Breaker Manufacturc: f��-�S Sizc 2`� Model'_+i�ber �C�7 M 2. Locaud At S� � I'�tQ�C� Scrial N�bcr �0�3,3� REDUCED PRESSURE PRINCIPLE:�.SSE!�iBLY I PRESSURE VACUIJM BREAKER Double Check V alve Assembly lst Chec�: Znd Checl: Relief Valve Air Inlet Checic Valve Iniaal Tat DC-Closad Closcd Ti�ht �(' Ogened at Opmed at nsid Ti�it 2• � 24. Leal:ed 2 Z 7 nsid osid RP-_,psid L,eai;ed D Did not Opea 0 I.eal:ai ❑ �P� and MaUerials Used Tcst After DC-Closcd Closed Tight o Qpeaed at Opeaad at nsid Rcpair Tiaht � nsid osid RP sid The above is certi6ed to be true. Firm Name �('�-101'1 ��Y2 I�D� Cerrified Tes�a IX�CD�n t1t;STc�f1 Firm Address ��� 7�� Cert. Testa No.��Oc�l bC�S� Dau�LS t1�0.uc l�a CI�t,Q �SC (�auge # O�(j OU7� llate last accuracy tested 5 White- Customer's Copy Yellow - City Copy Pink-Tester's Copy