2015_0102 (3) CIIECK ONL':
IRRIGATIUN llOMESTIC � FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: G�u � CG(��11
PWS I.D. #
LOCATION OF SERVICE: �1 �J� I'�'I G rl�a-{�iur bl�d • CaAUP�I, ��'. �S�I S
�'he backflow prevention asseinbly detailed below has been testcd and maintained as required by TCEO
regulations and is ceriified to be operaling within acceptable parameters.
TYPE OF ASSEMBLY
❑ �teduced Pressure Principle ❑ Pressure Vacu�Breaker
� Double Chcck Valve � A�osphere Vacuum Breal:er
Maaufact�er �nl�S Size ���
Model Iv�bcr �,�� F�1 I,ocaud At � �e��
s�►�N�b� AGa-cx�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSL'RE VACUUM BREAIL'ER
Double C3etk v alve Assembiy
1st Chec3: 2nd Checl: Relief Valve :�r Inlet Check Va1ve
Ininal Test DGClosod Closed Ti�ht � Opened at Opcaed at osid
Ti�t � Lcal:cd � psid �sid
�iSs �-�sid
Leai;ed o Did noc Opeu ❑ Leal:ed o
Regairs
and
Materiais
Used
Test ARer DGClosed Closed Tight o Opened at C?pcned at nsid
Rcpair Ti�t o �sid osid
RP sid
Zhe above is certified to be we.
Firm Namc p I� TPsi' __ Ccrr�ificd Testa 4„Ji��>4�'r1 �o�un
Firm Addr�ss � 4� ar�� �e� cat T�cer No. f�P�016 r I� Dace ( �1��5
�. W� �• ����.�ty
c3auge # 6 S I 3�b I 5
l�ate last accuracy 2ested �� (U - ��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy