2016_0331_RPZ CFIECK ONE:
IKRIGA't'ION DObiESTIC x FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR7
NAIv�OF PWS: `�� ?,`I, C' (� Lc';:.��rt�
PWS I.D.#
LOCATION OF SERVICE: /� _I)11/1�1��
The hack(lo��� ��re�ention assemhl}' detailed bcl�»��ha� been tc�!cd and maintained as required by TCEQ
re��ula�ions and i� certificci lz� be o�eratin�����ithin acceptable p��rameters.
TYPE OF ASSEMBLY
� Reducrd Pzessure Principle � Pressure Vacuum Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacture: �,{//lKl1✓.� Size 3�►
Model�i�ber +�7'� LocaudAt /�lS�,l� �DC�/�1
s�;�t�;,�b� L9/(a�3g
REDL'CED PRESSURE PRINCIPLE:�.SSE:�iBLY I PRESSURE VAC[TUM BREAI�R •
Dauble Check V alve Assembly
t ��� lst C3ec1: 2ad Checl: Reiie{y alve Air Inlet Check VaIve
Iniaal Tat DC-CIoscd Closed Tight �' Opcaed at Opened at nsid
TiQht `�` Lcal:ed ❑ 'Z`0 osid osid
RP-�sid
L,eai;�d c Did not Open Q Leal:ed o
��
and
Matcrials
Uscd
Tcst ARer DGClosed Closed Tight o Oppned at Opcacd at �sid
Repair Tight ❑ vsid osid
RP sid
The above is catified to be true.
Firm Name A�-��pr1 �t"I Y� YQD S Certifi�Testa � ��l
Firm Address �X 7 Cert.Tesur No. t��CQ�C(oSl Dau s„�
SlL{G(Q GG►(� �Tx
Gauge # �(p//�Q��
llate last accuracy tested��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy