2014_0813_RPZ C�IECK ONE:
IRRIGATION DOMESTIC v FIRELINE
BACI{FZ.OW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPORT
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NAME OF PWS: �`1 �� C,bD�D���
PWS I.D. # ����� �?J�
LOCATION OF SERVICE: �O5 N� ��n-��n Ta� �d •
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operaling within acceptable parameters.
� TYPE OF ASSEMBLY
Rcduc�Pressure Principle ❑ Pressura Vacu�Breaker
❑ Double Check Valve c Am�osphere Vacuum Breaker
Maaufact�cr Siu
3�,�,�
Model Ivumber `��ZQ�j� Locaud At �"�-�v�U�n(.c�Qi ��.5�
Scrial N�ber �Y. �2�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Cherk Valve Assembly
lst Checl: 2nd Checl: Reiief Valve Air Inlet Check Valve
Inival Test DGClosed Closcd Ti;ht Opened at Opened at nsid
c Ti C� Leal:ed ❑ � .� psid _�sid
�S J R.P�•�Dsid
Leai:ed ❑ �' � Did not Opea o Leal:ed ❑
�P�
and
Mataials
Used
Test ARer DGClosed Closed Tight o Opened at Opcaod at nsid
�� Tl�l� � DSId DSld
RP Sld
The above is catifiod to be we.
Firm Namc �II ��.�� Cerdfiod Testc �'✓ w'' "'�`�
Firm Address �S`�� M��1'VG�Li�I. U Lf.ln� Cert. Testa No.�� ��Q Date �`�3 `{
�0�� ��� � ����
c��ge # ��'�u�,t g
llate last accuracy tested � • � �•�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy