HomeMy WebLinkAboutPLIRR2015-3546CITY OF GRAPEVINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: GRAPEVINE ANNUAL TEST
IRRIGATION,,
PWS I.D.# 2200013 I 11 OTHERU
NAME OF BUSINESS WHERE DEVICE IS LOCATED: NQ� �UN)aH �ildlAl
ADDRESS OF SITE SERVICED: 51-1 5 • D00le1
PLUMBING PERMIT IF APPLICABLE: #
TESTER LICENSE NUMBER: BP a
DATE OF LAST TEST GAUGE CALIBRATION:
EXPIRES: � k
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
X DOUBLE CHECK
_ATMOSPHERE VACUUM BREAKER
MANUFACTURER: SIZE:
r I 1
MODEL: �So SERIAL NUMBER: AS I-1 S Mb
PHYSICAL LOCATION OF METER:
The above is certified to be true.
TESTERS FIRM NAME: Nll Ii
ADDRESS: JIMA Kaki, 9UNA CITY /STATE /ZIP: �,A ue*k
DATE:t SIIS PHONE NUMBER: �11'�1� Ot65
PRINT NAME: �V1A EIIfwOv� SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST BE CALLED FOR INSPECTION AT (817) 410 -3010
0.,FORMSSDS IRRIGATION INFOABACKFLOW TES'FREPORTA.c
Rc,,d'. 1'06,V10
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
DOUBLE CHECK
VALVE
ASSEMBLY
RELIEF VALVE
AIR INLET
CHECK VALVE
1sT CHECK
2ND CHECK
Open at _ psid
_ psid
DC -Clo Tight
Clo d g _ i ht
Initial
1-4 psid
(- �
Opened at
Did
Test
_RP
not open
Leaked
Leaked
Leaked
psid
off
Repair
Materials
Used
Test
DC- Closed Tight
Opened at
Opened at
After
Closed Tight
p sid
Repair
_ RP _ psid
_ psid
_ psid
The above is certified to be true.
TESTERS FIRM NAME: Nll Ii
ADDRESS: JIMA Kaki, 9UNA CITY /STATE /ZIP: �,A ue*k
DATE:t SIIS PHONE NUMBER: �11'�1� Ot65
PRINT NAME: �V1A EIIfwOv� SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST BE CALLED FOR INSPECTION AT (817) 410 -3010
0.,FORMSSDS IRRIGATION INFOABACKFLOW TES'FREPORTA.c
Rc,,d'. 1'06,V10