2016_0212 CHECK ONE:
IRRIGATION DOMESTIC FIRELINE ' � SS
BACI�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF FWS: ���?`l G� � L c�n��!I
PWS I.D. #
LOCATION OF SERVICE: 7�d G�r� l✓���
Thc backila��� prevention ass�mbly detailed belo�y� has been te�tcci and maintained as required by TCEQ
1•egulatrons and is certified to be a�erating within acceptable parameters.
TYPE OF ASSEMBLY
o Rcduced Pressurc Priaciple o Pressure Vacu�Breaker
� Double Chxk Valvc ❑ A�nosphare Vacuum Breal:er
_ � ,
Manufacturer 1�G �� 5 Siu . �� �
Model Nt�ber G�7 ►"'1 r� Locaud At L'c 5 � U c�c i
s��N�b� 3 d �3 �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CULJM BREAKER
Double Check Valve Assembly
lst Check �nd ChecR Reiief Valve :�ir Ialet Check Va1ve
iaiaal Test DC-Closed Closed Ti�:t ❑ Opened at Opeaod at nsid
Ti�t ❑ Leal:cd ❑ nsid _�sid
.�<<-� RP-,�psid
��� Leai:ai ❑ Did not Qpea o L,oal:ed ❑
�� v �, pr�� 3 � , n� h �.� �
and
Maurials
Used
Test After DGClosed Closed Tight o Opcaod at Opcaod at __nsid
Repair Tight o � osid __nsid
RP � sid a`
The above is c«tifiod to be true. y�' S
Fum Name A�?���1 � z Cectifiod Testa _�W�y►�� W Cv�H�
Firm Address 1'J(3�x' 7 9 7 Cat Testa No. C�ct�9�lJ� Date ���a /�G
(,�c� ?�C 7s�bs
Gauge # � 3 v���!�
llate last accurecy tested 3�5
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