HomeMy WebLinkAboutPLBG2015-2779CITY F PEVI E
BACKFY OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS; GRAPEVINE ANNUAL TEST �--�
PWS I,D,# IRRIGATION 2200013 OTHER
NAME OF BUSINESS WHERE DEVICE IS LOCATEb:.
ADDRESS OF SITE SERVICED; "� :` - '?� : �JLt { t•rti"`� _ ` . -..
PLUMBING PERMIT IF APPLICABLE; #
TESTER LICENSE NUMBER: N-7_`��''j EXPIRES: 'f7
DATE OF LAST TEST GAUGE CALIBRATION;
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
DOUBLE CHECK
MANUFACTURER;
PRESSURE VACUUM BREAKER
ATMOSPHERE VACUUM BREAKER
SIZE;
MODEL; �) SERIAL NUMBER;
PHYSICAL LOCATION OF METER;
/
TESTERS FIRM NAME: C:g/J��C��!`fJ
ADDRESS; 4�6 2•6i� CITY /STATE /ZIP;
DATE; _ ' j `` PHONE NUMBER;
PRINT NAME; �-� J :�--5
_ > SIGNATURE;
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