W Sandy Lk Addn-LR06033106/ II_11_JF tag: 40 9„�56 PCI COP!'= TPIJCTION I IC PAGE 02/
04/05/2006 12:57 972g231516 ACTION AUTOrJATIC SPR PAGE 02/03
CTIBCK ONE:
IRMOATIION DOMEs'I'IC FIREL NB
BACX3FL PR EL VSrT'f7lON SLY TEST AND bLUNM dANCE REPORT
NANM OF P'WS-
PWS I.D. i 1/C!
LOCATION OF SERVICE: �T .T ►4 ►.r �,� 41m 20
Thr- backflow prelenfion assembly detailed below hag been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
Rrduced Pressure Pri=ple
Double Check Valve
Maaufa+ca:rer W 4775
Model N = ber Q Q ? Vvt t Ct .
Serial N=brr / 5 a d W
Located At � E Cb r m ew 12 ir,
The above is certified to be true. )
Firm Name �'�.em u r, ,ae�, t. Catfied Tester \ 12 79 AL
Fum Address !6JCK'7 0 W 0Y D+ ?5 )dry'' Cart Tester o. QQ
Gauge # s2�
Date ,feat accuracy tested /C} —
TYPE OF ASSEMBLY
0 Pz'es5= Vacuum Bred=
Q Atmespbere Vwuum Breaker
r4
Size
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED MSSURE PRLNCIPLE
ASSEMBLY
PRESSURE VACUUM BREAKER
Double Cbeck Valve Assembly
1st Check
tad Cbeck
Relief VslYe
Air Inlet
Check Volvie
bidal Test
DC- Closed
Closed Tint
Opened at
Opened At
p aid
Tight
P1. P1. Sid
Leaked _ D
_psid
Mid
Leaked c
Did not Open M
Leaked ❑
and
Materials
Used
Test AS=
DC- Closed
Closed Tivgbt t7
Opened at
Opeard at
H ain
Repair
Ti& D
_ p sid
_____ _p jtid
RP
The above is certified to be true. )
Firm Name �'�.em u r, ,ae�, t. Catfied Tester \ 12 79 AL
Fum Address !6JCK'7 0 W 0Y D+ ?5 )dry'' Cart Tester o. QQ
Gauge # s2�
Date ,feat accuracy tested /C} —
TYPE OF ASSEMBLY
0 Pz'es5= Vacuum Bred=
Q Atmespbere Vwuum Breaker
r4
Size
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy