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IRRIGATION llOMESTIC FIRELINE k
BAC'I�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CG���
PWS I.D. #
LOCATION OF SERVICE: ���� �4�e U}e t�1 �I�- ��ppell �X� 7SG�y
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
t-egulations and is certitied to be operating �vithin acceptable parameters.
TYPE OF ASSEMBLY
❑ Re�uc�Pressure Principte ^ Pressure Vac��Breaker
'� Double Check Valve ❑ Amoospherc Vacuum Breal:er
Manufact�er �li��►�� Size ��
Model Number �S G�� Locaud At U�4�T �� W, �U''�r/'
s��N�ba �y 3 3► �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSLZtE VACUUM BREAKER
Doubie Check v alve Assembly
1st Checi: 2nd Checi: Relief Valve :�ir Inlet Check Valve
Ininal Test DGClosed Closed Ti;ht�!` Opeaed at Opened at osid
Ti�t� v � Lcal:cd 7 psid osid
Q S SS RP-_psid
Lcai;ed ❑ �'� Did not Oprn o Leal;ed o
�F�
and
Mataiads
Used
Test After DGClosed C1Qsed Tight ❑ Opencd at Opmcd at �sid
Rtpair Ti�t ❑ osid nsid
R.P sid
The above is cudfied to be truc.
Firm Namc ��� IQ.� r Certified Testc �Jr I�,`4M CiO�C�h
Firm Address �S''� h��r}'•'� ��p Jr Q� I n- Ccrt. Tester No. �PUO�61 J 7 Date � ' �� �
f t� i..xirt� �- 1 C1��'�
c�auge # OS13(�1 S
l�ate last accuracy �ested (�- (U- � "t
White - Custorner's Copy Yellow - City Copy Pink - Tester's Copy