2014_1023_RPZ (6) C�IECK ONE:
IRRIGATION llOMESTIC FIRELINE
BACI�I.OW PREVENT'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ,
PWS I.D. # �
�n �
LOCATION OF SERVICE: �OO. 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
Reducrd Pressure Principle ❑ Pressura Vacuimm Breaker
❑ Double Chcck Valve C Amlosphere Vacuum Breal:er
�
Manufact�er a Siu �/�
Model Number D�� Located At 5 w MaC�•hfC
Scrial N�ber ��aa�7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�'ER
Double Check Valve Assembly
lst Check 2nd Checl: elief�alve d►ir Inlet Check Valve
Iniaal Test DGCloscd Closed Ti;ht o�at Opened at nsid
Ti Leal.ed ❑ �{ psid _osid
� ��s�a 5.�
� �
Lcai:ed ❑ Did noc Open o Leal;ed ❑
Rcpairs
and
Mataials
Used
Test After DC-Closed Closed Tight O Opened at Opeaed at nsid
Repair Tight ❑ �sid nsid
RP sid
The above is certified to be uue.
I f
Firm Name l �5� Certifiod Tcstc � /l
Firm Addrass � ' � Cert Te.ster No. ba l�1� Date
�- 1�.�� ')l.c�y4.
Gauge # Q(Q07prj(Q�
i�ate last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy