2014_1023_RPZ (5) C�IECK �NE:
IRRIGATION llOMESTIC FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ,
PWS I.D. # �
�r, 1 r
LOCATION OF SERVICE: �OO. N • �'�mv+ 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
Qf Rcducrd Pressure Principle ❑ Pressura Vacu�Brcaker
❑ Double Chxk Valve ❑ Atmosphere Vacuum Breal:er
Manufact�er d Size ��a N
Model Numbcr ��� Located At �la�d 1/�� �/! �
Scrial N�bcr ���w�V
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Chec1. 2nd Chec1: 'ef Valve Air Inlet Check Valve
Ininal Test DGClosed losed Tight Op ed at Opened at nsid
Ti�� � Leal:ed o _�gsid osid
���L RP __psid
7 Lcai:ed ❑ ��� Did not Oprn o Leal:ed o
��
and
Materials
Used
Tcst Afttr DC-Closed Closed Tight o ppencd at Opmed at nsid
Rtpair Tight ❑ osid osid
RP sid
The above is catiSed to be true.
I � ` '.��
Firm Name l (�5� Certified Testa �JV�/�
Firm Address �� ' � Cert. T�No. ���1�1� Date
�. �►.�� �(��y�,
Gauge # Q(QO7D�Q�
llate last accuracy tested �
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy