HomeMy WebLinkAboutPLIRR2015-3074CITY OF GRAPEVINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE
REPORT
NAME OF PWS: GRAPEVINE
PWS LD.# 2200013
NAME OF BUSINESS WHERE DEVICE IS LOCATED:
ADDRESS OF SITE SERVICED:
ANNUAL TEST
IRRIGATION
OTHER
PLUMBING PERMIT IF APPLICABLE: #
TESTER LICENSE NUMBER: 6Pr ,)-T � IcyD -1 EXPIRES:
DATE OF LAST TEST GAUGE CALIBRATION: +.
THE BACKFLOW PREVENTION ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED BY
TCEO REGULATIONS AND IS CERTIFIED TO BE OPERATING WI'T'HIN ACCEPTABLE PARAMETERS.
TYPE OF ASSEMBLY
_REDUCED PRESSURE PRINCIPLE
✓' DOUBLE CHECK
_ PRESSURE VACUUM BREAKER
ATMOSPHERE VACUUM BREAKER
MANUFACTURER: _s SIZE:
MODEL: Q, SERIAL NUMBER: Z 7
PHYSICAL LOCATION OF METER.
The above is certified to be true.
TESTERS FIRM NAME::
ADDRESS: �,i" c. CITY /STATE /ZIP:
DATE: t= ` PHONE NUMBER: V7 m `4kZA —CA= ,(
PRINT NAME: SIGNATURE:"
DOUBLE CHECK VALVE INSPECTION MUST BE CALLED F" 7t INSPECTION A T (817) 410 -3010
O: \FORMS \BACKFLOW REGIS'rRATION.doc
1 1 /3 /2000 /Rev. 4/26/05
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
DOUBLE CHECK
VALVE
CHECK
ASSEMBLY
AIR INLET
VALVE
1s' CHECK
2 "n CHECK
RELIEF VALVE
DC-Closed Tight
Closed Tight
Open at _psid
psid
Initial
RP - psid
Z;3
Opened at
Did not open
Leaked
Test
Leaked
Leaked
psid
Repair
Materials
Used
Test
DC- Closed Tight
Opened at
Opened at
After
Closed Tight
psid
Repair
RP _ psid
psid
psid
The above is certified to be true.
TESTERS FIRM NAME::
ADDRESS: �,i" c. CITY /STATE /ZIP:
DATE: t= ` PHONE NUMBER: V7 m `4kZA —CA= ,(
PRINT NAME: SIGNATURE:"
DOUBLE CHECK VALVE INSPECTION MUST BE CALLED F" 7t INSPECTION A T (817) 410 -3010
O: \FORMS \BACKFLOW REGIS'rRATION.doc
1 1 /3 /2000 /Rev. 4/26/05