HomeMy WebLinkAboutPLBG2015-0816 I o: City of Urapevine Page I of I 2U1b-04-13 2U:b1:45(GM 1) 1665641 b3131 From:JOnn Davis
MAY 13 2015
GITY OrrGRA.PEVINE,
BACKROW PREVENTION ASSErVIBLY TEST AND MAINTENANCE
"VEPORT
NAME OF PINq: GRAPEVINE
ANNUAL TEST
.PPS LD,.#, 2200013 IRRIGATION
WAME OP BUSINESS WHERE DM 40tlj'-�. 77,ug,
CE IS LOCATED4 I q,
U q 1,07 Yq
-Aoj>RE-ss or-we:sERvICED: 67ro,��
PtUNIRING PERMIT
WAPPLIC , E:
TESTER LICENSE INUMSER:
Expwis
GATE OF LAST TEST GAUGE CALISRATIO
THE SA0fMQW PREVENTION ASSEP48LY.DftAILED MOW HA&OLM 7E3TM AND AlAWTAINED AS RjOUIRW Sy ToEct
MGULAInONSAND 16 CERTIFIED TQ 4E OPERATING WITHM ACCEPTAOLF PARAMETERS.
TYPE OF ASSEM-BLY
RmUCED pRESSURE pRINCIp,F,
PRESSURE VACUUM BREAKER
DOUBLE:CHECK ATMO-apHERE VACUUM SR
EA
MANUFACTURER: A "",,"' SIZE.
MODEL: S5ooQ10 3 SERIAL NU:7-
i PHYSICAL LOCATION
Pe-
Reduced PfQn P&OWO Assembly
D0111116 Check Vahre AsaacMV, Air lowa
Check VaW*
.. ist Check 2nd Ohogk
77wal DPC-C br d ti gj� opened at
Test 3P I
ps a Pdld a :Did nee open Leaked i
Leakod Eeakad
Rupsis De-oused right Mosad-ugh[
—RP__ opened at
p-4 Pam
HsCd
The above is cenmed to Ian Emu.
TESTERS FJJ9M NAWIE. AVE
A DATF, '7)c zrima
DDRES0,M012, CITYISTAI EtZIP,
PHONE NUMBER"
PRINT AAA S CJt4 f C SIGNATURE,
.ALI
El
DOUBLE CHECK fil'SPECTfON
olfus CALiED FOR fN,'rPEC TION A T
(8171 -410-30 10
0--AF0RQAl0ACKFL05iv