2014_0821 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE �
BACI�LOW PREVENTION ASSEMBLY TEST AND MAIlVTENANCE R�Fi�"
NAMEOFPWS: �!"?`l C� F' Cr_-(-)��-[1
PWS I.D. #
LOCATION OF SERVICE: ��� S /YOt.1��
Thc backflow prevention assei��bly detailed belo���has been test�d and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vactnmm Breakes
� Double Chcck Valve � Atmosphae Vacuum Breaka
�
Manufacturcr a �� Siu
Model Nimmber �� 7" ��� Locaud At 1��U �� CS� CoYY�-�'
s��N�v� loo�75
REDUCED PRESSURE PRINCTPLE ASSEMBLY I PRESSURE VACiTIJM BREAI�R
Double Cbeck Valve Assembly
lst Check Znd Chec{: Relief Valv� :�ir Ialet C3eck Vaive
Iniaal Test DGClosed Closed Ti�ht ,ei� Opened at Opeaed at �sid
r�� 3.2 �' Leal:ed � g ❑ nsid osid
R.P-_psid
Lcal:ed ❑ Did not Opea D Leal:ed ❑
�P�
and
Materials
Used
Test After DGClosed Closed Tight O Op��ai Opeaed at __nsid
R,epair Ti�aht O nsid osid
R.P sid
The above is catifiod to be�ue.
Firm Name�C�(o►� �Ire P2e c c�s�a r� � 't�ah 1-f�ST�r�.)
Firm Address YD�7CI7 CeR Tester No. OQ�OCoS Date_����/
�Q�C�fl�1G�'GG�ce T�
Uauge # �f/(�Q��
llate last accuracy tested �J c�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
C�IECK �NE:
IRRIGATION DOMESTIC FIRELINE�
BACKFLUW PREVENT'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAMEOFPWS: Lr�?`I G'� [r;���l1
PWS I.D. �
LOCATION OF SERVICE: �lI � 6(��'r�
The backflow prevention assembly detailed belo���has been tested and maintained as required by TCEQ
regulations and is certitie�d Co l�e operating within acceptable parameters.
TYPE OF ASSEMBLI�
o Reduced Pressure Principle ❑ Pmsure Vacuimi Breaker
❑ Double Chxk Valvc ❑ Atmosphere Vacuum Brealcer
Manufacturer ��G11�'ts Sizc 3l � �/
ModeIN�ber C�/77�1 LocaudAt �1�(';� �'1" U�/(1 CC�{�!/l.�i�
serial NUmber Y'��ST
�
REDUCED PRESSURE PRINCIPLE ASSEMBLY I PRESSURE VACU[JM BREAI�R
Double Check�alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inirial Test DGCloscd Closed Ti�ht �� Opened at Opcne�at vsid
Ti�t 2•(� � Leal:ed ❑ nsid osid
�-_ps�d �2.2
Leal:ed o Did not Opea O I,ealced O
RePairc
and
Maurials
Used
Test After DGClosed Closed Tight o pp��at ppcaed at �sid
Rtpair Tight O nsid osid
R.P sid
The above is certified to be�ue.
Firm Name �1 n VI t�(Y2 �205 Catified Testa� � �TO�
Fi:m Address Y���oJ� ���_ Ccrt Tester No. � Date 8 �
�a�{�!.�(�J� ��.
c�aug� # ,�(o//O��S
llate last accuracy tested ( 5 �i/
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy �