2014_1023_RPZ (2) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAC�'LOW PREVENT'ION ASSEMBLY TEST AND MAIlV'TENANCE REPORT
NAME OF PWS: �
PWS I.D. # � � �� ��
LOCATION OF SERVICE:_ �SD N . ��v, o�
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable paranleters.
� TYPE OF ASSEMBLY
Reducrd Pressurc Principle ❑ Pressuro Vacu�Brcaker
o Double Check Valve ❑ A�osphere Vacuum Breal:er
Manufacz�er �d Size ��
Modei Ivumber DI�� �� Located At �o�� r00+N�
S����b� A��03
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubte Check Valve Assembly
lst Check 2nd Checi: Reiief Valve :�ir Inlet Check Va]ve
Inival Tcst DGClosed Closed Ti;ht Opeaed at Opened at nsid
Ti�t Leal:ed ❑ ���D- psid osid
�� RP- $�,psid � �
I,cai:ed ❑ ' 1 Dia noc open o I.eal:ed o
�P�
and
Mataials
Uscd
Tcst Aft�er DGClosed Closad Tight ❑ Opencd at Opeaed at nsid
Rtpair Tight ❑ osid osid
RP sid
The above is certifie�to be true.
I J
Firm Nama L I�S� C«tifiod Testa �
Firm Addrtss�� �� ' ✓�. • Cat Tester No. �� l�1� Date
�. �o ���y�:
Gauge # 0(Qt�70�
llate last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy