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HomeMy WebLinkAboutPLBG2018-3061 BUG 16 ZW') CITY 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 LOCATED: ADDRESS OF SITE SERVICED: G �_ S __ �.r eiS *13e_ PLUMBING PERMIT IF APPLICABLE: # 0-e— TESTER LICENSE NUMBER: 1,(7I EXPIRES: DATE OF LAST TEST GAUGE CALIBRATION: 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. wTYPE OF ASSEMBLY _REDUCE RE S URE PRINCIPLE _PRESSURE VACUUM BREAKER DOUBLE CHECK _ATMOSPHERE VACUUM BREAKER MANUFACTURER: i r P SIZE: c� MODEL: lam" ©U�IM�L?( SERIAL NUMBER: cy- PHYSICAL LOCATION OF METER: REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER DOUBLE CHECK VALVE ASSEMBLY AIR INLET < CHECK VALVE 1sT CHECK 2ND CHECK RELIEF VALVE FDC-Closed Tight Closed Tight Opened at Open at_paid psid ln _RP 2 7psid Did not open Leaked _ Leaked Leaked psid Repair Materials Used Test DC-Closed Tight Opened at Opened at After Closed Tight _psid Repair RP_ psid _psid _psid ��p j The above is certified to be true. TESTERS FIRM NAME: ^e%nl Cle Ee• d A f V��S�L�7I/ �q, ADDRESS: /93/ / / LC��Q� I�� CITY/STATEIZZI�P: _Ovv' 'p✓tlG DATE: �ry (�} ( Y PHONE NUMBER: PRINTNAME: SIGNATURE: DOUBLE CHECK VALVE SP �TION MUST BE CALLED FOR kSWECTION AT(817)410-3010 QTORWDS=GAnONtIT01BACICFI.OW S ORT.doc Revis 1/46,2/10 _