2014_1009 (2) C�IBCK ONE:
IR.RIGATION � DOMESTIC FIftELINE
BACKFLOW REYENTION ASSEMBLY TEST AND NANCE REPORT
�o e �S e►-v l'c�
rr�oF Pws: f'� �/ .� 5
Pws I.D.#
,
LOCATION OF SERVICE: I ��� rQ� �Y ��✓
The bacl�low preveation asscmbly decailed below has been tested and maiataincd as required by TNRCC
regulanons aad is ccdfied to be operating withia acccptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Priaciple ❑ Pressure Vacuum Breaker
� Double Check Valvc ❑ Atmosphere Vacuum Bnaker
t � ��T'1"`� Size Zr�
Maaufacturer
Model Ivumber W7 � I � Located At �� O� � G
Serial Nianber � � ��� `��
��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUIJM BREAI�R
Double Cherk Valve Assembly
lst Checl€ �� 2nd Checl:�� ��{��ve :�ir Inlet Check Valve
• Inidal Test DC-Closed Closed Ti;ht o Opeaed at Opened at osid
�l Ti�ht ❑ Lc�l:cd o psid osid
f RP-_�sid
Q� L,eal;ed a Did not Opan o Lealced o
��
and
Materials
, Used
Test After DGClosed Closed Tight o Opened at Opeaed at �sid
Repair Tight o �sid _osid
RP sid
The above is certifiod to be true.
Firm Name � � � � �S T� . Cerdfied Testa�'6 ��� � I �
Fi:m Address � ���`^'t'Q►�1�1 �� Cert.Tes�er No. ��`��� Date I b � /�
Gauge # 7iS���
llate last accuracy tested � � ��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy -
C�IECK ONE:
IR$IGATION ✓ DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIN'I'ENANC'E ItEppRT
NAME OF PWS: �a P�P�I� -�-5� �'�JJ j CQ- `..,�t�`r1"�
PWS I.D. #
LOCATION OF SERVICE: 13�� �ra� '�� r,✓
�,
The bacl�low prevmtioa asscmbly desailod below has beea usted aad maintained as require� by TNRCC
regulanons aad is certified to bc opera�ng withia acccptable paramcters.
TYPE OF ASSEMBLY
❑ Reduced Press�e Principle ❑ Pressure Vacu�Breakcr
t� Double Chcck Valve o Amzosphere Vacuum Brea�er •
� . �,,
Manufact�er �-eb Sizc
Model Number � �� Located At �`��� �� " � C''
Serial Nimnber � � � I�
��� .,
{ �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACiTUM BREAI�R
Doubie Check Valve Assembly
lst Che Z i3 2nd Checl:Z��- Relief Valv� :4ir Inlet Check Va1ve
� Iniaial Test DC-Closed � � � Clos�d Ti�ht �D Opeaed at Opened at osid
� Ti�i 'p� Leal:ed o psid __„�sid
� RP-_,psid
Leal:ed 0 Did not Open o I,eaked O
��
aad
Materials
Usod
Test After DGClosed Closed Tight o Opeaed at Opened at _�sid
Rtpair Tight a _osid osid
RP sid
The above is cerdfiod to be true.
Firm Name� PI I ��p Certi,fied Testa �G U!�q � 1 r �
!\ � Q �f
Fi�m Addrcss I�0� t�ro� �" '� Cat T'ester No. ��5v Date �a c1 �%
Gauge # �� Qn�
llate last accuracy tested / � t �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
r
CFIBCK ONE:
IItRIGATION �/ DOMESTIC FIRELINE
BACI4'I.OW PREVENTION ASSEMBLY TEST AND MAINZ'ENAN(�REppRT
NAME OF PWS: `..££)(�P�I I .1- S� �U I C,�'- C.,�I'h'r"�J'"
PWS I.D.#
LOCATION OF S1�ItV�CE: 3 f(,�1'1 E� �t�'
�
The baci�low p�eation assembly detailed below has been tested aad maintaiaed as requind by TNRCC
reguladons aad is certified to be operating within acccptable parameteis. .
- TYPE OF ASSEMBLY
❑ �educed Pressure Principle o Pressure Vacuum Breaktr
� , � Double Check Valv� o Amzosphere Vacuum Breaker
Maaufacturer ��p�� , Size ��� >
Model Number ��� Locatad At /�O�l. �t�(�
Seriai Nimnber '� a�A t �
�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubi�Check Valve Assembly
lst Che 'Z,� 2nd Checi: 2,'j ��f Valv� Air Inlet Checit Valve
°� Ynirial Test DGClosed- Clos�d Tight � Opeaed at Opeaed at �sid
, � Ti�t � Leal:ed psid _„osid
+ �a RP-_psid
�� Leal:ed o Did not Open o I,eal:ed o
�P�
and �
, Mataials
Used
Test ARer DC-Closed Closed Tight o ppeaed at Opcaed at _nsid
Repair Tight 0 ,_��sid ' osid
RP sid
The above is certifiod to be tirue.
,
Fum Name � � Ca�tificd Tcster �� '
Firm Add�ss V� V' Cert. Tescc No. ����Date �� T
Gauge # ��
llate last accuracy tested � � r�
White- Customer's Copy Yellow - City Copy Pifik-Tester's Copy
%