2014_1023_RPZ (4) C�IECK �NE:
IRRIGATION llOMESTIC FIRELINE
BAC'KFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: .
PWS I.D. # �
�1 tr� �
LOCATION OF SERVICE: I DO. N • � v� e�
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
Rcducrd Pressure Principle ❑ Pressur�Vacuimm Brcaker
o Double C k Valve o A�osphere Vacuum Breal:er
Manufactiaer �/"�' Siu �/�N
Model Number l�� Located At �t'O��,L ��c*rl� ����(,
Scrial N�ber �$a����
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst C3eck 2nd Checl: elief�%alve :�ir Inl�t Check Valve
Iniaal Test DGCloscd Closed Ti;ht at Opeued at nsid
Ti�t Leal:ed ❑ ► psid nsid
��� RP-�,psid 4
Lcai:ed ❑ 0 '0 Did not Oprn o Leal;ed o
Rtpairs
and
Materials
Used
Test After DGClosed Closed Tight o Opmcd at Opmed at nsid
Rtpair Tight ❑ nsid nsid
RP sid
The above is carifiod to be true.
� I
Firm Name L I•�5� Certified Tute �k�V1
Firm Address�� � ' � Cert. Testa No. �a �1�1� Date
�. 1�� ��c�`l�.
Gauge # Q(Qt�70�j(Q�
llate last accuracy tested (( �
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy