2014_1023_RPZ (3) c�iEcx uxE:
IRRIGATION DOMESTIC FIRELINE
BAC'KF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # �
I r-
LOCATION OF SERVICE: �OO. � • �'F��.+ 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
Reducrd Pressure Principle ❑ Pressur�Vacuimm Breaker
7 Double Check Valve o A�osphere Vacuum Breal:er
� N
Manufact�er a Size
Model Number f/U� Located At � 1�.� W�N� 1A,v� �'�n�
s��N�ba �y�0(BS
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�'ER
Double Check v alve Assembly
lst Check 2ad Chec1: Relief�alve Air Inlet Check Valve
Iniaal Test DGClosed Closed Ti;ht �at Opened at nsid
Ti�t Leal:ed ❑ � psid _osid
RP-�psid
�� Lcai:ed � �' � Did noc Opea � Leal:ed o
Repairs
and
Materials
Uscd '
Tcst After DC-Closcd Closed Tight o pp��at Opmed at nsid
Rrpair Tight ❑ osid nsid
RP sid
The above is cerrifi�d to be tirue.
1 I �
Firm Name L I•�5� Ca�fied Testa ��NL
Firm Address �� ` � Cert. T�No. b��1�1� Date
� �� �����.
Gauge � Q�Qp70�Q�
llate last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy