2014_0725 C�IECK ONE:
IRRIGATION� DOMESTIC FIRELINE
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BACI�ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PWS: ��'����/
PWS I.D.#
LOCATION OF SERVICE: � �5 Y � �z 7"� � ��c- � I ���(
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
� Rcduced Pressure Principle ❑ Pressure Vacu�Breaker
Double Chcck Valve o Atmosphere Vacuum Brcaker
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Manufact�er �fEx� Siu ` �
Model Number a .S� Located AL hCx�" -f� S�`v�t' �`�/�
Scrial N�ber ��� � / ���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2ad Checl: Relief Valve Air Inlet Check Vaive
Inival Test DGCloscd� Closed Ti;ht � Opeaed at Opened at nsid
Ti�i � Leal:ed o �sid osid
RP-_psid �
Leal:ed 0 J. 7i Dia noc opca o Leal:ed 0
�P�
and
Materials
Used
Test.4ft�er DC-Closed Closed Ti,Qht o Opencd at Opmed at _nsid
Repair Tighi � �sid osid
RP sid
The above is certified to be true.
Firm Name �G cF� P�� ���!�`I�f"� CertiSed Testa c� �e � / ' � c J�c'�
r
Firm Address �� � CJ�� Cert.Tester No. Z S'� Dace��=��
--f r� 1��.� � 75��
Gauge # �J�t 3
llate last accuracy tested -��l
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy