HomeMy WebLinkAboutPLIRR2015-3566CITY OF GRAPEVINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: GRAPEVINE
PWS I.D.# 2200013
NAME OF BUSINESS WHERE C
ADDRESS OF SITE SERVICED:
PLUMBING PERMIT IF
TESTER LICENSE NUMBER:
DATE OF LAST TEST GAUGE CALIB
ANNUAL TEST
IRRIGATION
THE BACKFLOW PREVENTION ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED BY
TICE Q REGULATIONS AND IS CERTIFIED TO BE OPERATING WITHIN ACCEPTABLE PARAMETERS.
TYPE OF ASSEMBLY
REDUCED PRESSURE PRINCIPLE
_ZDOUBLE CHECK
PRESSURE VACUUM BREAKER
ATMOSPHERE VACUUM BREAKER
MANUFACTURER: (y% C 0 SIZE: (IG/
MODEL: R�L7 SERIAL NUMBER:
PHYSICAL LOCATION OF METER: (', ^' &�Lk
The above is certified to be true.
TESTERS FIRM NAME:
ADDRESS,: LL'MM —CITY/STATE/ZIP: R W L�{L
DATE: ` � ) PHONE NUMBER: 1311 - 31 ci - S
PRINT NAME: CA( 1 5 IA((P SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST BE CALLED FOR INSPECTION AT (817) 410 -3010
O: WORIAMS REGISTRATION FORMS \TCEQ BACKFLOW TESTER REGISTRATION Coc
11 /31WIRM 1105, 11W, Z10
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
-Close ` Tight
Closed Tight
Initial
_RP psid
,
Q_ �
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,: LL'MM —CITY/STATE/ZIP: R W L�{L
DATE: ` � ) PHONE NUMBER: 1311 - 31 ci - S
PRINT NAME: CA( 1 5 IA((P SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST BE CALLED FOR INSPECTION AT (817) 410 -3010
O: WORIAMS REGISTRATION FORMS \TCEQ BACKFLOW TESTER REGISTRATION Coc
11 /31WIRM 1105, 11W, Z10