2014_0718_RPZ C�,✓E,q�� `� r
C�IECK i�NE:
L-��s��s ��, � `Z-
IRftIGATION DOMESTIC � FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATTON OF SERVICE: 777 ��orzr Pcc.,_ S�,�/30 _ �j TJ�• �f S'�! �
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reducrd Pressure Principle ❑ Pressure Vacuimm Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breal:er
Maaufacturer �✓/�� Size
�y
Model Number �/ �2 Lncated At �D DKOG,�sSs ��ie�
S����b� 3 z � 2�� �r�yy� a,� e.�w„�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Check Valve Assembly
lst Checl: 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DC-Closed Closed Ti;ht �ened at Opened at osid
Ti�t � Leal:ed o �psid __,nsid
�S RP-?�Dsid 7,�'
7-1�� �f LcaI:ed ❑ Did not Opea o LeaI:ed o
�P�
and
Materials
Used
Test A.fter DGClosed Closed Tight o Opened at Opcaed at nsid
Repair Tight ❑ osid nsid
RP sid
The above is ccrtifiod to be true.
Firm Name � �/�ST" BA�I°'�Ga Certified TGster t� J'.
Firm Address•2�S�� SlA�E�.�f�� T.�C Ccrt. Tester No. O/0�7 Date �/ ��
/��j2 i Lr4�/D 7jG �.5�'Z-,6
c�suge # lbd 9b3�7
llate last accuracy tested (�2�j -/�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy