2014_1023_RPZ C�IECK ONE:
IRftIGATION llOMESTIC FIRELINE
BAC�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �
PWS I.D. # � 1n, � � ���� �tnR�Q�.
LOCA7TON OF SERVICE:_ �SO N . �'1�Ov� 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 parail�eters.
� TYPE OF ASSEMBLY
Rcducrd Pressure Principle ❑ Pressurc Vacu�Breaker
� Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size ���►y
Model Numbcr ��� Located At �OL� i'vV1,.
Scrial N�ber /'f10:� ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAb'ER
Doubie Check Valve Assembly
lst Check 2nd Checl: elief Valve Air Inlet Checic Valve
Iniaal Test DGClosed Closed Ti�t • at Opened at nsid
Ti�L.L Leal:ed � psid ��osid
D�/L RP-�psid
1 �/ Lcai:ed ❑ ��0 Did not Opea o Leal:ed o
��
and
Mataials
Used '
Test After DGClosed Closed Tight � Qpared at Opcned at nsid
Repair Tight ❑ osid osid
R.P sid
The above is catified to be tzve.
I J I
Firm Name t �5� Certified Testa �k�Wl
Fum AddrGss �� ' • Ccrt. Tester No. ���1�1� Date
�-- �� ��1��4;
Gauge # �(Qt�1 Drj(Q�
llate last accur�cy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy