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2014_1009 C�IECK ONE: IRRIGATION ✓ DOMESTIC FIRELINB BACKFLOW PREVENTI�N ASS LY TEST AND MAINTENANCE REpOR? NAME OF PWS: �rP��� I � I�� °tr. ��OD� U�✓� PWS I.D.# LOCATION OF SERVICE: I� �1�J R��!� Y The bacl�low preveation assembly detailod below has beea tested aad maintaiaed as requirrd by 'INRCC regulanons aad is certified to be operating withia acceptable parameters. TYPE OF ASSEMBLY ❑ Reduced Pressure Principle ❑ Pressure Vacu�Breaktr � Double Chxk Valve o Atmosphere Vacuum Breaker Manufacturer �.�.�Q TPT Size Zr/ Model Number [J�� � r � Located At ��'r C"`� Serial N�mmbcr � ��� r REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Doubie Check Valve Assembly lst Check Z� � 2nd Checl: Z�D �ef Valve Alir Inlet Check Va1ve 1ni � Test DGClosed Closed Tight �6 Opeaed at Opeaed at nsid r_� Tight �d Leal:cd o psid _osid Ql� RP-_psid Leal:ed ❑ Did not Open o L,ealced o �P� aad Mataials Used Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at _nsid Rtpair Ti�hht � _�sid nsid RP sid Tlie above is cGrtified to be true. j,� , Firm Name �� �� Catified Teste � �1 Firm Address ������� � � ✓ Cert.Teste No ��1� Date �d g 1� Gauge # ��� llate last accuracy tested / S � ! White- Customer's Copy Yellow - City Copy Pink-Tester's Copy C�ISCK ONE: IRftIGATION_�_ DOME$TIC FIftELINE BAC�I.OW PREVENTION ASSEIV�LY TES?AND NANCE REppRT NAME OF PWS: C�O o 1 �'S''�� PWS I.D.# � � LOCATION OF SERVICE: � r Y �r The bacl�low preveation asscmbly decailed below has been tesud and maintained as required by TNRCC regulations aad is cudfied to be operating within acccptable paramcu�s. TYPE OF ASSEMBLY ❑ Reduced Pressure Principle ❑ Pressure Vacu�Breaker �!` Double Check VaIve o Amaosphere Vacuum Breal:er Z�1 Maaufactiaer � '� Size Modei Ivumbtr ��� � , Located At E� 5'� o� ���nn� Serial Nu�ber t-t "C� �P�� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check v alve Assembly lst Check Z,, � ?nd Checl: 2.1 �ef Valv� :�ir Inlet Check Valve :R Inidal Test DC-Closed Closed Tight � Opeaed at Opeaed at ,_nsid Ti�t �- Leal:cd ❑ osid __,nsid Qo-�� RP-_psid � Leal:ed � Did not Open o Leal:ed o �� and Materials Used Test ARtr DC-Closed Closed Tight 0 Opened at Opened at _�sid Repair Tight � _�sid nsid RP sid 'Ilie above is ccrtifiod to be true. Firm Name��OP_I� .1 S� . CatiSed Tcsta� �� � Firm Address I� Cert. Tester Na � Date �� � Gauge # ��QD llate last accuracy tested � (� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy