2015_0615 CFIECK �N�:
IRRIGATION llOMESTIC )O FIRELINE
BAC'KFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAMEOFPWS: L��?`I �' � Lc�n�J��1
PWS I.D. #
LOCATION OF SERVICE: `� '�� �� �-i c 1
Thc backflow preventic}n assembly detailed below has been tested and maintained as required by TCEQ
rc�ulations and is certifiEd to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduc.�Pressure Frinciple Q Pressure Vac��Breaker
� Double Check Valve ❑ Amnosphero Vacuum Breal:er
Maaufact�er W�L�.H S Siu o�
Modei'vtmiber 3�� Locaud At �. 5��c � �7's:� %
Scrial Nimiber �4� � �`'r 7�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V:�CUiTM BREAKER
Doable Check Valve Assembly
lst Check 2nd Checl: Reiief Va1ve :�►►ir Inlet Check Valve
Inival Test DGClosed Closed Ti,Qht�7 Opeaed at Opened at �sid
Ti�c � � � Leal:�d�,�� ❑ osid _osid
��.,1; RP-_psid
Lcat:ed o Did not Opea o Leal:ed ❑
�P�
and
Matesials
Used
Test AR�er DGClosed Closed Ti�t o Op��at Opeaod at nsid
Repair Tight 0 _nsid _,_nsid
R.P sid
The abovo is certifie�to be true.
Fi:m Name /��Ti��-► �---- Certified Testa 1--�W��...c (ti��, „►—
Firm Address � d�� ��5� Ceri. Testet No. �':x')�i Cl J y Date `���5
I�'� ��" ���G�"
Gauge # ��c>c,aJ ��'
llate last accuracy tested `�/�7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
C�IECK ONE:
IRRIGATION�_ DOMESTIC FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
N.4ME OF PWS: �-i��`I G� � Cc�,-��t>
PWS I.D. #
LOCATION OF SERVICE:
Thc backflo��� prevention assembly detailed belo��r has been te�ted and maintained as required by TCEQ
reguf��ti�ns and is eerti�ied to be ��erating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Rcduc.ai Pressure Principle ❑ Pressure Vacu�Breaker
� Double Chxk Valve ❑ Amzosphore Vacuum Breal:er
Manufacturer f�,'a-�--►> Size �
Modei Nt�ber (�7 wl � Locaud At 5, 5 �J� LcJ L`in r�,y ��, ���w�-
Serial N�ber (�7 `/c�'��
REDUCED PRESSIJRE PRINCIPLE ASSEMBLY PRESSURE VACiJUM BRE.4I�R
Double Check�alve Assembly
lst Check 2od C3ecR Relief Valve Air Inlet Check Valve
Inival Test DGCloscd Closcd Ti,�ht �8b Opened at Opcaed at nsid
Tight �.� � Leal:ed �,S o _nsid ��sid
�C� 4 t RP-_psid
Leal:ed ❑ Did not Opea D Leal:ed ❑
Repairc
and
Mataials
Used
Test Aftrs DGClosed Closed Ti,Qht o Opeaed at Opcaod at __nsid
Repait Tight o _osid nsid
R.P sid
The above is cctificd to be tivc.
Firm Name�Q� 7��d� ���A Certified Testa �c,��.��-- W z�,N -�-
Firm Address I-�� �✓�'N 7C1 1 Cat Tester No. G�C��c�l�� Date �.� �S
�,lf Q�`- 'f y �3!ty 3
Gauge # G��a���� ►�S
llate last accuracy tested '3/��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
CFIECK ONE:
IRRIGATION DOMESTIC FIRELINE �
BAC'I{F'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAMEOFPWS: L��?`I �' � Cc��1GJ�t/
PWS I.D. #
LOCATION OF SERVICE: `��� S• e���
The backflow prevention assembly detailed belo��� has been tested and maintained as required by TCEQ
rebulatiuns and is certitied to be operating ���ithin accepCal�le parameters.
TYPE OF ASSEMBLY
❑ Rcduccd Pressvrc Principle o Pressure Vaca�mm Breaker
� Double Check Valve ❑ Atmosphere Vacuum Brealer
Manufacturer I.+�a�� Siu �l�'f
Modci N�ber ��+ � Locaud At Ak��r� Uc>v��
Scrial Nimmbcr 3��:'� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BRE.�R
Double Check Valve Assembly
lst Checl: 2nd Checl: Relief Valve :�ir Inlet Check Valve
IniQal Test DGClosed Closed Ti;ht � Opmed at Opened at �sid
Tight �� �i7 Lea}:ed �� 0 psid nsid
�,7 5 �--.ps�a
Leal;ai o Did not Opea O Leal:ed O
�P�
and
Mata-ials
Used
Test Af�er DGClosed Closed Tight o Openod at Opeaod at nsid
Repair Tight [J �sid nsid
RP sid
The above is ccrtifiai to be avt.
Fum Name /-�t'�r�3,n ���� Certified Tesur 1-��Je.�-�� W��.�--
Firm Address � � 7 9� Cat Testc Na �C�►%Na 3' Date ��S//S`
�Q,c �7� �7 5/G�
Gauge # ��v,C��� �C�S
llate last accuracy tested 3��5
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
C�IECK �.INE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAMEOFPWS: L��?`l G� F� L'r�(-�A��I
PWS I.D. #
LOCATION OF SERVICE: `I 5 � �- iC�v c t
Thc backflo��� preventi�n assembly detailed belo�v has been te�ted and maintained as required by TCEQ
i-ebulations anri is c�rtified to be operating �vithin acceptabl� parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle o Pr�ssurc Vacu�$reaker
j� Double Check Valve o A�nosphere Vacuum Hreal:et
Manufacturer I�c-��*5 Siu B
Model N�ber '7a `I Locaud At /L�r-nn V��.'�
Scrial Nimmbcr �� 5� 7'3
REDUCED PRESSURE PRINCTPLE A.SSE?ti1BLY PRESSURE VACITUM BREAKER
Double Chetk Valve Assembly
lst Check 2nd Chect: Relief Vaive :,ir Inlet Checic Valve
Iaiaal Test DGClosed Closed Ti�t �B Opened at Opeaod at _�sid
Ti�t 3 .�, ,gP Leal:ed;�-� ❑ �nsid osid
�S; RP-�psid �
Lca�:ed 0 Did not Opea o L,eal:ed o
�P�
and
Mataials
Uscd
Test ARer DC-Closed Closed Tisht o ppened at Opeaod at nsid
_-s
Rcpair Ti,hc a _nsid nsid
R.P sid
The above is ccrafiad to be true.
Fum Name.A��Tzc>� �'✓`= Certifi�d Testa �I,�k:M N L W�`C�')�y
Firm Addr�ss���� 7 i� Cat Testa No. �'Oc 9��� Date ���� �'3
kl�y -�� �s�c;.;
Gauge # d�c�}'��-�
llate last accuracy tested 3/•�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy