2017_0203 CIIEC� �NE:
IRIiIGATIOI�i DCiMESTiC FIIi.ELINE �?
BAC'I{FZOW PREVENTION ASSEMBLY TEST AND 14iAiNTENANCE REPOR?
NAMEOFPWS: �-r ► `I L� � Lc-,(-��rl!
PWS I.D. #
LOCATION OF SERVICE:�i.� i C, �c,n�l� � e�UY_
Tl�e backtlow preventior� assembly detailed bclo�-�� has been testc� and maintained as required by TCEQ
regulations anc� is c�rti�ieti tc� be ��perating ���itt�i�1 acceptable: par-ametzrs.
TYPE OF ASSEMBLY
C Reducad Pressure Principle � Pressure Vacnum Breaker
�G' Double Chxk�i alve G A�osphcre Vacuum Breal:er
,
Manufac:urer �c>T i 5 Size c�
Model Number � � `� Located At �:,��'%�� ���::� 'i
Scrial N�unber �C5� !7 I
REDUCED PRESSURE PRINCIPLE:�.SSEI�IBLY PRESSURE V�CL3i,TM BREA�R
Double Check�alve Assembly
Ist Checl: 2nd Chec1: Reiitf Valvt :�ir Inlei Chetk Va1ve
Iniaal Ttst DGCIos Closed Tight �85' Opeaed at Opened at nsid
Ti�t �� � Leal:ed . .j G osid nsid
�U,�i5 RP-_._.psid �%!
° Leai;ai o Did not Qpen o L,cal:ai o
Renairs
�a
Materials
Used
Test Af�er DC-Closad Closed Tight ❑ Opaned at Opcaed at Dsid
Repair Tight a �sid nsid
R.P sid
The above is certified to be t�ve.
Firm Namc r�i��� .� �i�� __ Certifiod Testa 4�1•�.-�a K t Ir-�r�+n��
�iim Acldress,�c'� r �(' ��7Ci�7 Cert. TGsta No. �'iCc� c�l�) Date��;�Z
�.���Y rY �7,�1G�"
, ,
Gauge # ��� c��i. �,.) ,,�
llate last accuracy tested �j//(,
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE�`
BAC�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �r�?`l C� (\ L'r�(-����C
PWS I.D. #
LOCATI�N OF SERVICE: I� � l� �rl�L/ � �'--
The backfl�«,� preventio�i assembly detailed belo��� has been t�stcd anci maintained as required by TCEQ
re�ulations and is certitied to be operatin� within aceeptable parameters.
TYPE OF ASSEMBLY
C Reduc�d Pressure Principle fl Pressure Vacu�Breaker
�' Double Chcck Vaive o Armosphere Vacuum Breaker
Manufac:urez t.Jc "�-r i Size �� 4
Model Number ��7 7`( Located At [4-� � �.�n�>._. ;
scrial lv�bcr rv�i ��'c��,.
REDUCED PRESSURE PRINCIPLE:�.SSEMBLY PRESSURE VACUiTM BREAI�R
Double Ch�rk v alve rl�semblv
� lst Checl: 2nci Chec1: Relief Valve Air Inlet Checic Valve
Ininal Test DC-Closed Closed Ti;ht ,�� Opened at Opened at nsid
Ti�t �,��v � Leal:ed�.�c; � _nsid nsid
�C`. h� RP-`�sid
lrcai;ed e Did not Open o L,eaiced ❑
R,enairs
and
Materials
Used
Tcst?�Rer DC-Closed Clesed Tight o pppa�at Ogcnai at nsid
Rtpair Tight ❑ _ osid vsid
R.P sid
The above is ceatifiod to be t�ue.
Firm Name�C��Ic�.�, ��� Cectified Tcstu �ir�F=y�� i,�� v� ✓� �-
Firm Address pci �X.�i� �7�l`7 CeR Tester No. [`r-i> >=1� °i Date�13/��
�f,��� i� "7�1G's
Gauge # �?�G�.�}�a i��.
llate last accuracy tested �//�,
White - Customer's Copy Yellow - City Copy Putk-Tester's Copy