2016_0309_RPZ c�i�c� ux�:
IRRIGATION llOMESTIC`�)� FIRELINE
BACKF'LOW PREVENTION ASSEMBLY TES'T AND MAINTENANCE REPORT
NAME OF PWS: L r'?�I C� � t r_'t'-n-���1
PWS I.D. #
LOCATION OF SERVICE: ��7 W �C +r1 a1 L r� ��
Thc hackflo��� prevention assembly detailed below 11as been tested and �naintained as required by TCEQ
re�ulat�ions and is certiti�d lo be operating within acceptable parameters.
TYPE OF ASSEMBLY
t� Rcduced Pressurc Principle ❑ Pressure Vacu�mm Breaker
❑ Double Chcck Valve ❑ Armosphac Vacuum Breaker
Maaufacturer W 4 i r S Siu o?
Model N�ber Cb 9 r'� � Locaud At �J� �+1 d I L i� C 1� �t i�� �v-
Scrial Ni�ber l vd7 c� a
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACiTUM BREAKER
Double Check Valve Assembly
lst Checl: ?ad Chec1: Retief VaIve Air Inlet Check Va1ve
Iuitial Test DGClosed Closed Ti�ht � Opeaed at Opened at �sid
n p y y Ti�t y � Leal:ed ❑ ��rsid __osid
1 RP-�sia ci.o
Leal:ed � Did not Opea o L,eal:ed O
�P�
and
Materials
Uscd
Test After DGClos�d Closed Tight o ppeaed at Opeaod at _nsid
Repair Tight o nsid osid
RP sid
The above is certified w be�ue. U-r 5
Firm Name� ��� �:-L C«tifi�d Testa 1-��.1�y h-r W L�„ e--
Firm Address�o P�� ��� W�x Cert.Tester No. ovo 9NJ� Date 3�g I i�
Tx 7s���
Gauge # (� �G���1�
Date last accuracy tested 3/��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy