2014-0612 C�rIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�'LOW PREVENT'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: .
PWS I.D. � �
�1 1n 1 �
LOCATION OF SERVICE: IOO. N • �'1��+ e�
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
o� Reducrd Pressure Principle ❑ Pressuro Vacu�Breaker
�� Double Check Valve C Atmosphere Vacuum Breal:er
1 '"
Manufact�er �, Size
Model Number lJ�� Located At �V�.��C`
Scrial Ni�bcr Ho���OU
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check V alve Assembly
lst Checl: 2nd Checl: Relief Valve :�ir Inlet Ch�ck Va1ve
Ininal Test DGClosed Closed Ti�t Opened at Opeaed at osid
Ti�t,.' Leal:ed ❑ psid _nsid
-�ry+5 �- -� S�a 1 �
j.C3l:Cd ❑ r Did not Opca 0 I.C3�Cd ❑
Repairs
and
Materials
Uscd
Test Aft,er DC-Closed Closed Tight o ppencd at Opeaed at nsid
Repair Tight ❑ osid osid
R.P sid
The above is certifie�to be true.
I � � �a�
Firm Namc l �5� Cctified Testa uJll�►
Firm Address�� �h ` • Ctrt. Testa No. b��1�1� Date
�-. 1�� ��c�`l�.
Gauge # 01Qt�705(�
llate last accuracy tested ((
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy