2014_1023_RPZ CIrIECK I�NE:
IRRIGATION DOMESTIC FIRELINE
BACIQ�I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NANIE OF PWS: ,
PWS I.D. # �
�1 tr� �
LOCATION OF SERVICE: IOO• N • � v+ e�
The backflow prevention assembly detailed below has been tested and maintained as required by T�EQ
regulations and is certified to be operating within acceptable parameters.
/ TYPE OF ASSEMBLY
d Reduc�Pressure Principle ❑ Pressure Vacuimi Brealcer
❑ Doubl heck Valve C Atmosphere Vacuum Breal:er
I N
Manufacturer � Size
Model N�mmber �d� Locatcd At ��� � �Ilif1 '�
Serial N�bez �U.a��l�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAk'ER
Doub[e Check v alve Assembly
lst Checl: 2nd Checl: Relief Valve alir Inlet C6eck Va1ve
Iniaal Test DGClosed Closed Ti�ht ❑ eaed at Opened at nsid
Tieht ❑ L -ed �psid _nsid
RP-_psid
H�'� Lcai:ed Did not Open o L,eaked o
�P�
and
Materia[s
Uscd
Test After DC-Closed Closod Ti,Qht O Opened at Opeaed at nsid
Rtpair Tight ❑ osid nsid
RP sid
The above is certifiod to be uue.
1 l
Firm Name � (�57" c�s�a T� �nn n
Firm Address �� ' � Cat Testa No. ���1�1� Date
�. 1�� ��c�y�.
Gauge � Q(Q�7�j(Q�
llate last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy