2015-0908 (6) CHEC� ON�: �
IftRIGATION llOMESTIC FIRELINE x
BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NA.�vfE OF PWS: �� i` C� F� - �«
PWS I.D. n
LOCATION OF SERVICE: Q� �Y.ee dor-�- Pk��y
Thc hack t1o���pre��ention assembly detailed b�lo���� has�ieen tosteci and maintained as required by TCEQ
re�ulatio��s aild is certitied lo be operating�vithin aeceptable pzirameters.
TYPE OF ASSEMBLY
❑ Reduc�Pressure Principle ^ Pressure Vacuum Breaker
� Double Chxk Valvc c Atmosphere Vacwun Breaker
Manufacnue: 1-�-PrS.�c a Size 8�r
Model Iv�ber nr.nA Locatcd At �In1 C�'rv�.r Ft►�.e UAc.�I�-
s�►�N�b� �0��32
REDUCED PRESSURE PRINCIPLE:�SSE:�IBLY' ( PRESSURE VACU[JM BREAKER
Doubk C3etk Valve Assembly
lst Checl: 2nd Che�i: Reiief v alve :+llir Inlet Checit Va1ve
Inirial Tat DGClosed Closed Ti�.ht J$ Opened at Opcned at vsid
Ti�t 3 � 1�I Lcal:cd ❑ �sid nsid
RP-_psid �{"•�
Lcai;cd c Did not Oprn o L,eai;ed o
��
and
Mata-ials
Used
Test A.fta DC-Closed Closed Tight o Opeaed at Opeaod at osid
Rtpair Tight o flsid nsid
RP sid
The above is certified to be tive.
Firm Name�(''�-t 01'1 ��r.2 4�D� Ccrtified Tasta tX.iCO+n `ST�
Firm Address ��� 7�� Cert.Tester No.��Oc�i bL�51 Date 101�I I S
tua�ca h a Ch�e Tx
c�auge # D�9���7�
llate last accuracy tested j
White - Customer's Copy Yellow - City Copy Pink-TesteNs Copy