2015_1112 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE �
BAC�'LOW PREVENTION ASSEMBLY TES'T AND MAINI'ENANCE REPORT
NAME OF PWS: L�'?�,� G'' � L�c�(-���U
PWS I.D. #
LOCATION OF SERVICE: Is �� 5 �'/z e �a r �
The backflow prevention assembly detailed below has been Cested and maintained as required by TCEQ
rcgulations and is certified to be operating �vithin acceptable parameters.
TYPE OF ASSEMBLY
❑ Rcducrd Pressure Principle ❑ Pressure Vacuum Breaker
,$D Double Check Valve ❑ A�nosphere Vacuum Brealxr
Manufacttaa I,J c. T,'� S ize 3�`�
Model Number C�� vc� i Locaud At V��au��
Scrial N�ber � ,�C�9 U
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUiTM BREAKER
Double Chetk�alve Assembly
lst Checl: 3nd Checl: Reiief Va1ve alir Inlet Check Valve
Inival Test DC-Closed Closed Ti;ht �P Opened at Opened at nsid
Tidu �, .� R� Leal:ed � � ❑ nsid _osid
Qu�s RP-_�sid � �
Leai;ed o Did not Opm D Leal:ed o
�P�
and
Mataiats
Used
Test Af3rs DGClosed Closed Tight o Opeaod at Opeaed at __osid
Repair Tight o _�sid _�osid
R.P sid
The above is cerdfied w be true. �{ 5
Fum Name A���;n C;rt Ccrtified Testa �W�:..:-,c LJr_,,,,..r,-
Firm Addrcss p� �o ic 1 5 ? Ccrt Testc No. �c��9N�� Date � / �
�ilc� ,— � 75%��y
Gauge # ��.3c�,R��l,�
llate last accuracy tested -�/�S
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
C�IECK ONE:
IRRIGATION DOMESTIC � FIRELINE
BAC�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L r?�I G'' � Lc,T��'.�/
PWS I.D. #
LOCATION OF SERVICE: f73 5 Ft����r�
The backflow prevention as�embly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Ruiuced Pressure Principle ❑ Pressure Vacu�Breaker
� Double Chec�;Valve ❑ Amzosphere Vacuum Breal:eer
Manufact�cr '� (J�t fr�» 5 Siu � �
Model N�ber �!`��' �'t T 1 Locaud At � vvl c T�-'
Scria!Nianbcr `l � �.�7G.[>
REDUCED PRESSURE PRINCTPLE ASSEMBLY PRESSURE V�CUUM BREAKER
Doubk Check Valve Assembly
lst Check 2nd Checl: Relief Valve alir Inlet t�eck Va1ve
Inival Test DC-Closed Closcd Ti,�ht ,� Opeaed at Openod at �sid
Ti�t �p Leal:ed � L o _nsid __osid
�e a S RP-�sid '�' '
Lcai:ed O Did not Opea ❑ Leaked ❑
��
and
Mataials
Used
Test Aftes DC-Closed Closcd Tight o Opened at Opeaod at _�sid
Repair Ti�t o __osid _�osid
RP sid
The above is certifiod to be true. '�'T t
Fiim Name �}c 7w=�. F=-� Catifiod Testcr �W��,�.- W�•�K•-�-
Firm Address Qo ��k -7�°i � Cat Testa No. c>c-u�KJ� Date ��// �
I�c� � r� '�4 fG S
(Gauge # �3 v��� , ,;
llate last accuracy tested
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
CFIECK ONE:
IRRIGATION� llOMESTIC FIRELINE
BACI{F'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �-r'?`I G'' � c��A��/
PWS I.D. #
LOCATTOIv OF SERVICE: l� ��`.� I'�'�c�G�r �
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
rebulatians and is certified to be operatinb within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pmsure Principle o Pressure Vacu�Breaker
�17 Double Chxk Valve ❑ Atmosphere Vacuum BreaL-er
Maaufacturer 1.,� 1 L IC�v+5 Siu e� ,
Model Ivimnber �SC� X��T�_ Locatod At � v�l�'�'�°�
Serial Nimmber '`� ��c�7'�`7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUIJM BREAI�R
Double Chetk�alve Assembly
lst Check ?nd Checl: Relief Valve Air Inlet Checic Valve
Iui�a!Test DC-CIosed Closed Ti�ht � Opeaed at Opeaod at ��nsid
Tight 1� Leal:cd ❑ nsid _,_osid
�o �i� RP- ��Dsid ��U �
L.cakod o Did not Opea D I,eaked ❑
�P�
and
Matcrials
Used
Test ARar DGClosed Closed Tight o ppeacd at Opcaad at nsid
Rcpair Tis,,,ht ❑ __nsid osid
R.P sid
The above is catifie�w be true. �/�S
Fum Name A��'�u�n F'. -- Ccctified Tester �t�3c+..,v�c �..�r r,r. �-
Firm Address pv�'�x 7 5 � Ccrt. Teste No. c�c�`3�IJ� Date r i
(l�`�'` `r � '7.s 7 b�
Gauge # _��c7�;�3�L
Date last accuracy tested 3%ij
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy