2014_1023_RPZ (7) C�rI�C� ONE:
IRRIGATION llOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # �
,n �
LOCATION OF SERVICE: �DO. 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
Rcducrd Pressurc Principle ❑ Pressurc Vacuimm Breaker
o Double C k Valve C Amoosphere Vacuum Breal:er
Manufacturer �l Size
3�`
Modellvumber �d� LocatedAt �1� �h 1'V1I� •
Scrial Nimibcr ���iDD
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double C3eck Valve Assembly
lst Chec1: 2ad Chec1: 'ef Valve :�ir Inlet Ch�ck Va1ve
Ininal Tcst DGCloscd Closed Ti�t o�,at Opeaed at osid
Ti�i Leal:ed ❑ (I psid osid
�j�l�,� R.P-_�[psid �.�
Lcai:ed ❑ Did noc Opea o Leal:ed o
�P�
and
Materials
Uscd '
Test Af�er DC-Closed Closed Tight o Opencd at Opcaed at nsid
Rtpair Tight ❑ nsid nsid
RP sid
The above is certified to be true.
I � � �a�
Firm Name l �5� Cerdfied Tutc uJVV►
Firm Address ��+ ` � Cat TGstcr No. b��1�41�A Date
�- �� �c �C���.
(�auge # Q(Qd7D�Q�
llate last accuracy tested ({
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy