2014_1023_RPZ (2) C�IECK ONE:
IRRIGATION llOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: .
PWS I.D. # �
�-�1 �n �-
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
Reduc�d Pressure Principle ❑ Pressvrc Vacutmm Bceaker
❑ Double Chxk Valve C Atmosphere Vacuum Breal:er
'tr� 1 N
Manufaczurer W� Size h
Modei N�mmbcr W� Locatcd At � 1A `` "tn. �
5�;����� ��a��o
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAb'ER
Double Check v alve Assembly
lst Chec3: 2nd Checl: Relief Valve :�ir Inlet Check Valve
Ininal Test DGClosod Closed Ti�t ❑ Opeaed at Opened at nsid
Ti�t O -cd psid _�osid
�� I RP-_psid
� Lcai:ed Did not Open 0 Leal:ed �
��
and
Matcrials
Used '
Test After DC-Closcd Closed Tight ❑ Opened ae Opcaod at nsid
Repair Tight ❑ osid osid
RP sid
The above is ccti6ed to be true.
J
Firm Name � (�5� c«�s�a T� �rv► n
FirmAddress � ' • Cat T�No. ���1�7� Date
�-- 1�� ��c�y�.
Gauge # Q(QO7f1�j(Q�
�ate last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy