2016_0615 C�IECK �NE:
IRRIGATION DOMESTIC FIRELINE ��
BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAMEOFPWS: ���?`I G'' F� L��n�r_!1
PWS I.D. #
LOCATION OF SERVICE: ��D ��V t�
The hackflo�v prevention assembly detailed below has been tested and maintained as required by TCEQ
rebulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacu�Breaker
� Doublc Chccic Valvc ❑ Am�osphere Vacuum Breaka
Manufacturer � i ��Lil�ls Size ���
Modei Nimmber 3�JU��4 Locatod At �I�-2V��.1� �Q S'�' �Ctc.e:u►'1
s�;�r+�b� N���3a
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACLJiTM BREAI�R
�� Double Check V alve Assembly
Ist Checl: 2nd ChecR Relief Valve :�ir Inlet Ch�cic Valve
Inival Test DC-CIosed ,�-��L- Closed Ti;ht � Opened at Opmod at nsid
Ti�t � Leal:cd �j.� ❑ nsid osid
R.P-_psid
Leai:od ❑ Did aot Opea ❑ Leal:ed ❑
�P�
and
Maurials
Used
Test After DC-Closed Closed Tight ❑ Opeaed at Opcaod at nsid
Repair Tight o nsid nsid
RP sid
The above is cati6ed to be�ue.
Firm Name ��(DYl�-1 V';� 1'"/L.D S Certified Tcster Uu�d l.�t H-�/S To h
Firm AddrGss�0��7� Cer�Testa Na � S Dau_��?����
G�/a K�t l�acG�r,e �x
Gauge # _Q��!/�(y�j
llate last accuracy tested � 8 5
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy