2014-0612 (3) CIIECK �NE:
IRRIGATION ✓
DOMESTIC FIRELINE
BACI�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � U
PWS I.D. # ����,� l ��tl� � �J��
LOCATION OF SERVICE: ��� �� �� � 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
o / Reducrd Pressure Principle o Pressurc Vacu�Breaker
�� Do�ble Check Valve ❑ Aunospherc Vacuum Breaker
Manufact�er
U���\(�n.S s� � �jZ«
Model Iv�ber �O Located At l; ����. 1� T 1,�- V���VG�
Scrial N�ber r `�� l���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACLTUM BREAKER
Doubfe Checic Valve Assembly
lst Checl: 2nd Checl: Relief Valve :�ir Inlet Check Valve
Ininal Tes DGCloscd losed Ti;ht Opeaed at Opeaed at flsid
��SS \,� Ti� Leal:ed 0 psid �sid
���Zj R.P �sid
Lcai;ed ❑ o� �� Did not Open o L,eal:cd �
�P�
and
Materials
lised
Test ARtr DGClosed Closed Tight o Opened at Opmed at nsid
Rtpair Tight ❑ nsid osid
RP sid
The above is certifiod to be true.
Firm Name�.��, ���� Certified Testa
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Firm Address '�e���_ v�'C�"� Cat T�No. � �O�Date ' ��'
� ��o�� '���
G�uge # ��Q l� �lV GJ� �
llate last accuracy tested � ` �- - �
White - Customer's Copy Yellow - City Copy Pink- Tester's Copy