HomeMy WebLinkAboutPLIRR2013-1744J 1i 1\1 12 8 �-, 0 13
CITY OF GRAPEVINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: GRAPEVINE ANNUAL TEST
PWS I.D.# 2200013 IRRIGATION
OTHER
NAME OF BUSINESS WHERE DEVICE IS LOCATED:
ADDRESS OF SITE SERVICED:
PLUMBING PERMIT IF APPLICABLE: # Z,5-1741Y
TESTER LICENSE NUMBER: 1 —7 � EXPIRES:
DATE OF LAST TEST GAUGE CALIBRATION: .2 1:2,2 j . 3 21211bzo
THE BACKFLOW PREVENTION ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED By
TCEQ REGULATIONS AND IS CERTIFIED TO BE OPERATING WITHIN ACCEPTABLE PARAMETERS.
TYPE OF ASSEMBLY
REDUCED PRESSURE PRINCIPLE PRESSURE VACUUM BREAKER
_4 DOUBLE CHECK — ATMOSPHERE VACUUM BREAKER
MANUFACTURER: SIZE: 3AY
MODEL: L52 —SERIAL NUMBER:
PHYSICAL LOCATION OF METER: R;e4,� - c (
1 ne above 1s cemneo to be true.
TESTERS FIRM NAME: i)
ADDRESS: k9bii .0 1 CITYISTATE/23P• 1�'7111
DATE: i PHONE NUMBER: / 7")l
PRINT NAME SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST BE CALL OR 1NSPi;ION AT (817) 410-3010
C,iD000M-1%5b.UU.WALS-iVr&.P.XPOM.4-%TCEO &*=ft0WTEMR11FGmmT10N d-
1140OP",405. Ift. 2110
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
DOUBLE CHECK
VALVE
ASSEMBLY
RELIEF VALVE
AIR INLET
CHECK VALVE
1ST CHECK
eD CHECK
Z,&
DC-Clor,fd right
'dosed right
Open at _ paid
—paid
Initial
„_RP ; Ypsid
Opened at
Did not open
Leaked
Test
Leaked
Leaked
—wd
I
Repair
Materials
Used
Test
DC-Closed Tight
Opened at
Opened at
After
Closed Tight
Repair
RP
— _, paid
— paid
Psid
—paid
1 ne above 1s cemneo to be true.
TESTERS FIRM NAME: i)
ADDRESS: k9bii .0 1 CITYISTATE/23P• 1�'7111
DATE: i PHONE NUMBER: / 7")l
PRINT NAME SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST BE CALL OR 1NSPi;ION AT (817) 410-3010
C,iD000M-1%5b.UU.WALS-iVr&.P.XPOM.4-%TCEO &*=ft0WTEMR11FGmmT10N d-
1140OP",405. Ift. 2110