HomeMy WebLinkAboutPLIRR2015-3565CITY OF GRAPEVINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: GRAPEVINE ANNUAL TEST
IRRIGATION
PWS I.D.# 2200013 OTHER
NAME OF BUSINESS WHERE DEVICE IS LOC
ADDRESS OF SITE SERVICED: (1 S- (5 e4
PLUMBING PERMIT IF APPLICAI LE: # L
TESTER LICENSE NUMBER: P�66 M>
DATE OF LAST TEST GAUGE CALIBRATION
bDe� r 0 Uj�A--U J- k
EXPIRES: P- I
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 _ PRESSURE VACUUM BREAKER
__,D UBLE CHECK
/ _ ATMOSPHERE VACUUM BREAKER
MANUFACTURER: C t o SIZE: I l
MODEL: /� SERIAL NUMBER: rl Y��4(C
PHYSICAL LOCATION OF METER: (^ ,►' "�� v�
Itie above is certified to be true.
TESTERS FIRM NAME: A' 1 I
ADDRESS: kG ) I w� I �� (i I -M() 1 CITYISTATEIZII
DATE: I 6 -1 - 15 j PHONE NUMBER: P7
PRINT NAME: r 1 ✓��� SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST
0 WORMS= REGISTRATION FORMS \TCEQ BACKFLOW TESTER REGISTRATION doc
IVVWIREV V06. 11W MO
FOR INSPECTION AT (817) 410 -3010
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
��/`
nitial
DC-Closed Tight
CIO
�,
Opened at
_RP� psid
P
eight
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
_
Itie above is certified to be true.
TESTERS FIRM NAME: A' 1 I
ADDRESS: kG ) I w� I �� (i I -M() 1 CITYISTATEIZII
DATE: I 6 -1 - 15 j PHONE NUMBER: P7
PRINT NAME: r 1 ✓��� SIGNATURE:
DOUBLE CHECK VALVE INSPECTION MUST
0 WORMS= REGISTRATION FORMS \TCEQ BACKFLOW TESTER REGISTRATION doc
IVVWIREV V06. 11W MO
FOR INSPECTION AT (817) 410 -3010