2014-0612 (2) ChIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NANIE OF PWS: .
PWS I.D. # �
�n �
LOCATION OF SERVICE: �OO• N • � v� e�
The backflow prevention assembly detailed below has been tested and maintained as required by T�EQ
regulations and is certif7ed to be operating within acceptable parameters. '
TYPE OF ASSEMBLY
o/ Reducrd Pressure Principle ❑ Pressur�Vacu�Breaker
d Double Check Valve ��P� ❑ Amoosphere Vacuum Breal:er
Maaufact�er A. Size
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Model Number �� Located At N,h, t�'�'�'�v�CJc � c��
Scrial Nimmbcr � r� ' `��`f
REDUCED PRESSURE PRINCTPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check V alve Assembly
lst Checl: 2nd Checl: elief�alve Air Inlet Check Valve
Ininal Test DGClosed Closed Ti�t Opeaed at Opened at �sid
Ti�t Leal:ed � psid nsid
�b� R.P- +� psid ) �
L,cai;ed ❑ i Y Did noc Open � Leal.ed 0
�P�
and
Materials
Used
Tcst Aftu DC-Closed Closed Tight o Opcncd at Opcnod at nsid
Rtpair Tight o osid osid
RP sid
The above is carifi�d to be tnu.
f
Fum Name � �5� Catifi�d Testa ��
Fum Address�! �� ' � Cert. Tcstc No. b����1� Date
�-. 1►a� ��c�y�.
(�auge # 0�Qt710�
llate last accuracy tested (,(
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy