HomeMy WebLinkAboutPLBG2012-0269J,an 26 12 01:31 p 1 A Fire & Domestic Testi 817 232 5722 P.1
EMEME
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: GRAPEVINE ANNUAL TEST
IRRIGATION
PWS I.D.# 2200013 OTHER
NAME OF BUSINESS WHERE DEVICE IS LOCATED:
ADDRESS OF SITE SERVICED: tW 1_h =M,
PLUMBING PERMIT IF APPLICABLE: #
TESTER LICENSE NUMBER: -EXPIRES: _L4 IC(
DATE OF LAST TEST GAUGE CALIBRATION: 1� I D, I 1 ti
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
V
DOUBLE CHECK
ATMOSPHERE VACUUM BREAKER
MANUFACTURER: SIZE: cr
MODEL: S�-C> SERIAL NUMBER:.
PHYSICAL LOCATION OF METER:
TESTERS FIRM NAME:
The above is certified to be true.
ADDRESS: q.-0 •6L,e � n 4V - CITY /STATE /ZIP:
DATE: PHONE NUMBER:
PRINT NAME: i2_�, CA C', M-�� SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST BE CALLED FOR INSPECTION AT (817) 490 -3010
O: FCRMSIDS REGISTRATION F0RM%TCEQ BAO FLOW TESTER REGISTR0.T1014.600
11/31006X'. 4105. 1, 00, Zt10
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
DOUBLE CHECK
VALVE
AIR INLET
CHECK VALVE
ASSEMBLY
RELIEF VALVE
I ST CHECK
2"' CHECK
Open at — psid
psid
'
osed Tight
DC- 6c
��
Closed Tight
Opened at
Initial
,P t. i
_RP psid
Z, -0
Did not open
Leaked
Test
psid
-S -3
1 Leaked
Leaked
Repair
Materials
Used
Test
DC-Closed Tight
Opened at
Opened at
After
Closed Tight
psid
Repair
_ RP _ psid
psid
psid
TESTERS FIRM NAME:
The above is certified to be true.
ADDRESS: q.-0 •6L,e � n 4V - CITY /STATE /ZIP:
DATE: PHONE NUMBER:
PRINT NAME: i2_�, CA C', M-�� SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST BE CALLED FOR INSPECTION AT (817) 490 -3010
O: FCRMSIDS REGISTRATION F0RM%TCEQ BAO FLOW TESTER REGISTR0.T1014.600
11/31006X'. 4105. 1, 00, Zt10
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