2015-0908 (7) C�IECK ONE:
IRRIGATION x DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPQRT
NAMEOFPWS: �� J � � ���-r�
PWS I.D. #
LOCATION OF SERVICE: �� �r.ee�or�-� P1��,v�y
Thc backtlo���}�revention assembly detailed belo��� has been t�stcd and inaintained as required by TCEQ
r��.:ulations �nd is certtfied to be operating�v°ithin �cceptablc parameters.
TYPE OF ASSEMBLY
L Reducrd Pressure Princrole ^ Pressuro Vacu�Break,er
�: Double Chxk Valve � Atmosphae Vacuum Breal:er
Manufacn�e: �Q{'.YO Size '2�r
Model'vtmmber �� Locaud At � Y1�4-C►� h�,s �S�r.e.e�-{'
Seria!N�ber (�22�c(o
REDUCED PRESSURE PRINCIPLE:�SSE;KBLY I PRESSURE VAC[TUM BREAI�R
Double Check Valve Assemblv
Ist Checl: 2nd Checl: Relief 4 alve :�ir Inlet ChEck Va1ve
Initial Tat DGCloscd Closed Ti�ht j�f Opcned at Ogened at nsid
Ti�t � Lcakcd ❑ �sid osid
R.P- 2-�nsid �.2
Lcai;ed � Did not Open O Leal:ed 0
��
and
Mataials
Uscd
Test After DC-Closed Closad Tight o Opened at Ogeaod at nsid
Rcpair Tight o osid osid
RP sid
The above is cctified to be true.
Firm Namo �i Dlrl � 1�2 I�OS Certified Te:sta L�CO�n �-�t;ST�'l
Firm Address ��� 7�� Cat Te,sta No.'��D�l bC�S� Date JD�S
waxa h a c�,�.e T"u
Gauge # Ol9(��7�
Date last accuracy tested j
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy