2014_1023_RPZ (8) CI�IECK t�NE:
IRRIGATION DOMESTIC FIRELINE
BACT�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ,
PWS I.D. # �
�r� �
LOCATION OF SERVICE: �DO. N • � v+ e�
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
reguiations nd is certified to be operating within acceptable parameters. '
TYPE OF ASSEMBLY
Rcducrd Pressure Principlc ❑ Pressurc Vacuimm Brcaker
❑ Double Chcck Valve c Atmosphere Vacuum Breal:cr
I ''
Manufacturcr A Siu �
Model Nimmber ��� Located At �r►S 1/�� �wr IA�� �:n �
Scrial N�bcr l������
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Checl: 2nd Checl: elief Valve :�ir Inlet Checic Valve
Ininal Test DGCloscd Closed Ti�ht . at Opeaed at nsid
n Tieht Leal:cd � psid nsid
���� R.P- �� sid
Lcai:ed ❑ �° � Did noc Oprn o Leal�cd ❑
�P�
and
Materials
Uscd
Tcst After DGClosed Closed Tight o Opened at Opeaed at nsid
Rtpair Tight ❑ osid nsid
R.P sid
The above is ccxtified to be true.
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Firm Name ` �5� Gecdfied Testa �
Firm Address�� �N ` � Ccrt. T�No. b����1� Date
� �� �����,
(�auge # Q(Qp7DS(Q�
llate last accuracy tested ({
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy