2014_1009 C�IBCK ONE:
IRRIGATION ✓ DOMESTIC FIRELINE
BACKFLOW PREVENTION EN�LY TEST AND CE REPORT
NAME OF PWS: !E ��e��
PWS I.D.#
LOCATION OF SERVICE: � �� 'EY
The bacl�low preveatioa asscmbly dctailod below has ban tested and maintained as required by TNRCC
regulanons and is cerdfied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacui�Breaker
�' Double Check Valve ❑ Atmosphere Vacuum Breaker
Maaufacturer �e- �-d giu Z
1l
r � \�
Modei Number �S � Located At O� `�.lil�Q {3�'
Serial N�ber � 0 9 �o� ' ��" G�W 1
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACLT[JM BREAKER
Double Check Valve Assembly
lst Check 2.� Znd Checl: �, g�(��f Valve Alir Inlet Check Va1ve
Initial Test DC-Closed Closed Ti�ht Opeaed at Opened at _,esid
Ti�i � Leal:ed 0 nsid __��sid
�(j��j� RP-��sid
Leal:od ❑ Did not Open � Le�al;ed O
�P�
aad
Materials
Used
Test Aftar DC-Closed Closed Tight ❑ Opened at Opeaed at _�sid
Repair Tight o _nsid nsid
RP sid
The above is certified to be true.
1�'C `
Firm Name � .--L J Certified Testa Q�I� � ' �
Firm Address 3 w f A Y1 �►r Cert T�ter No. �S Date �
Gauge # _��J�jQI,�C/
llate last accuracy tested � �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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