2015-0908 (5) C�IECK UNE:
IRRIGATION llOMESTIC FIRELINE x
BACKFLOW PREVENTION ASSEMBLY TES'T AND MAINTENANCE REPORT
NAMEOFFWS: �-��7`I C'' � L�c(-�A���
PWS I.D. #
LOCATION OF SERVICE: q� �Y.ee7 or�- Pk��y
Th� backt]o��� �t-zvention assei��bly detailed belo�a� has heen tesl�cl and maintained as required by TCEQ
rc�ulatic�ns and is ccrtitied lo be operating witl�in acceptablc parameters.
TYPE OF ASSEMBLY
c Rcducrd Pressure Principle � Pressure Varu�Breaker
� Double Chxk Valve c Atmosphcrc Vacuum Breaker
Manufacturcr P►r�2 Size 3���
Model'_vumbtr �- Locaud At ,S(�.� �IY'2��Q u �-�--
Serial Niuuber ��(2��
REDUCED PRESSURE PRINCIPLE:�SSE:biBLY PRESSURE VACU[JM BREAKER
Double Check Valve Assembly
lst Check lnd Checl: Relief Valve 4ir Inlet Check Valve
Inival Tcst DC-Closcd Closed TiQht ,t� Opened at Opened at nsid
Ti�t ?•Qj �; Leal:cd � �sid osid
RP-_..,_psia 2•Z
Leai:cd ❑ Did not Open o Leal:ed ❑
RtPa;rc
and
Mataials
Uscd
Tcst Aftes DC-Closcd Ctosed Tight o ppened at Opcned at nsid
Rcpair Tight ❑ nsid osid
RP sid
The above is certified to be true.
Firm Namc �C'�-I DI�I ��Y'2 �DS Ccrtifiod Testa UL�Sdvl t-tUS�c�I
Firm Address ��� 7�� Cert.Tester No.���1 bC�51 Date 1 D��__�__I S
u�ax�h a ch�e rx
Gauge # O lv(�OC��7�
D�te last accuracy tested j
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy