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HomeMy WebLinkAboutPLIRR2016-1520 I CITY OF GRAPEVINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: GRAPEVINE ANNUAL TEST PWS I.D.# 2200013 IRRIGATION I T OTHER NAME OF BUSINESS WHERE DEVICE IS LOCATED: UC11F}tiap,� ,l.v�t`-� ADDRESS OF SITE SERVICED: I D,�l q T PLUMBING PERMIT IF APPLICABLE: #�LrR✓i -/(�- /S�(J TESTER LICENSE NUMBER: B200 O/S c 1 EXPIRES:_� I DATE OF LAST TEST GAUGE CALIBRATION: •�? 151 THE BACKFLOW PREVENTION ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED BY TCEO REGULATIONS AND IS CERTIFIED TO BE OPERATING WITHIN ACCEPTABLE PARAMETERS. TYPE OF ASSEMBLY REDUCED PRESSURE PRINCIPLE —PRESSURE VACUUM BREAKER DOUBLE CHECK _ATMOSPHERE VACUUM BREAKER MANUFACTURER: IAS 'A k: C SIZE/:: Y MODEL: sem© 11 SERIALNUMBER:__A5a60( PHYSICAL LOCATION OF METER:Q� Mid c r -Trr `yy� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER 7Leaked CK VALVE XBLY AIR INLET CHECK VALVE 2no CHECK RELIEF VALVE osed 7i ht ' Open at_psid _psid Initial t Opened at Test .1'� Did not open Leaked Leaked —Psid P�� Repair Materials Used Test DC-Closed Tight Opened at Opened at ArClosed Tight RepairRP_ psid paid psid paid //�� I The above is certified to be true. TESTERS FIRM ��N""AMM�E: /-t- PPtt'L I o ADDRESS S[�_y)taye4(_ze,•,k CITYISTATEIZI1P: r-FL4, ;Tn7C DATE: PHONE NUMBER: /' G PRINT NAME: SIGNATURE: DOUBLE CHECK VALV I S ECT1ON MUST BE CALLED FOR INSPECTION (817) 410-3010 C.:DWUNC-lbwuetLOCALS 11Tcnpwg%%%io\T E0 W'TE RREGIGfp WNEac vroNowpv.<ro5,tNi,vlg k-k CITY OF GGRAPEVNE BACKa L OW PREVEN T iCiN ASSEMBLY TEST AND MAINTENANCE REPORT !NAME OF PWS: GRAPEVINE ANNUAL TEST PINS I.D.# 2200013 IRRIGATION ,,`�_ OTHER (1 eC�.� NAME OF SUSINESS 'WHERE DEVICE IS LOCATED: /�� e(�(Jul ^ . ADDRESS OF SITE SERVICED. I/, l '1�� PLUMBING PERMIT IF APPLICABLE: TESTER LICENSE NUMBER: 113l EXPIRES: DATE OF LAST TEST GAUGE CALIBRATION: _ . 9 3 f THE BACKFLOW PREVENTION ASSEMBLY DE!'AILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED BY TCEQ REGULATIONS AND iS CERTIFIED TO BE OPERATING WITHIN ACCEPTABLE PARAMETERS. TYPE OF ASSENJEL°( _f REDUCED PRESSURE PRINCIPLE _ PRESSURE VACUUM BREAKER r DOUBLE CHECK _ATMOSPHERE VACUUM BREAKER MANUFACTURER: i (y�j SIZE: MODEL: _ 3 G J Q SERIAL NUMBER:_ PHYSICAL LOCATION Aumm9ft Reduced Prasam Principle Assembly Frossure Vacuum Breaker Double Chock Valva Assembly AG Well Check Valve Is Check 2nd Check Rermf Valva Open at_Paid _psid Pnidaf DC-Closed 71'gf Closed Tf h4 Test' 9P-�ps`i� g Opened at old not open Leaked Q/ paid Laakad L./ L fir•+- =Aftm �gntl Ctesad ghE w� =() d 4 sid �' Opened at Paid L f psid The above is cer#ified to be true. TESTERS FIRM a1IAME• c ADDRESS:, .o• l)� J"�� CiTYISTATJ?IP: _ /'f�1C� DATE— PHONE PLUMBER: 5 ?.?INT 'NAMME:S�j�jj�1 �), l J js SIGNATURE- Ali,r�k• AlCCte' tf'1.0 1J 11±iSt� IeT1{3113 oi%?diST� CAl i,D F(0r1?1111SAFC6' (677y -10-3010 D:IFORMIBACKFLOSY 119198