2014_0718_RPZ (2) C�IECK ONE: `�"��� �a��snc� � � Z.
IR.RIGATION DOMESTIC X FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAN�OF PWS:
PWS I.D. #
S"►� / O
LOCATION OF SERVICE: 77 Fiet� o �C . /9
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 ❑ Pressur�Vacu�Brcaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breal:er
Manufact�er �'`��� Size � y
Modei Number �a9�� Located At �/Vli/A/� //Cd 0 v�
Scriai Nimibcr �,1�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Check V alve Assembly
lst Check 2nd Checl: Relief Valve :�ir Inlet Check Valve
Inival Test DC-Closed Closed Ti�t � Opened at Opened at nsid
��s Ti�t }� Leal:ed � .2`� psid __nsid
RP•�sid !�D
?-l8-1� Leal;ed o Did not Open o LeaI:ed ❑
�P�
and
Materials
Used
Test After DC•Closed Closed Ti,Qht o Opened at Opeaed at �sid
Repair Tight o nsid osid
RP sid
The above is ceitified to be true.
� ��sT g�/o� � ��
Firm Name Certified Tester /�C�fA'J��
Firm Address ��/�ST�GG��oA�H ��CL. Cert. Testa No. 8 D�D,� ate�
i��2,�L�/p �. '7•S%Z�o
�auge # _ l00 9'0 3�"7
llate last accuracy tested l0 �����
White - Customer's Copy Yellow - City Copy Pink- Tester's Copy