2014-0612 (4) CIIECK UNE:
IRRIGATION DOMESTIC � FIRELINE
BACI�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: v�� �� C�PY�(.L�
PWSI.D. # � 1����5 ��J�
LOCATION OF SERVICE: �O") �V� �J�C�1/��✓� �GII� 1`'�
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 / Rcducrd Pressure Principle o Pressure Vacuimm Breaker
�' Double Chxk Valve C Atmosphere Vacuum Breal:er
Manufact�ser
WQ.� Siu ��1
Model Ivumber ���' Locaud At �' �i1��/�,I�� l.� T 1� V\��1/�`'I�L�
Scrial Nimmbcr ������
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve A►ir Inlet Check Valve
Iniaal Test DC-Closod Closed Ti;ht Opeaed at Opened at nsid
��S Tight� � Leal:ed o psid osid
R.P-_,psid
Lcai;ed ❑ a.� Did not Open o Lcal:ed o
�P�
and
Materials
Uscd
Test AR,er DGClosed Closed Tight ❑ Opened at Opmed at �sid
Repair TiQ,ht � nsid nsid
RP sid
The above is cerdfiod to be true.
i
Firm Name I��I I ���CS� Certified Testa � �
Fi:mAddress�5�� �`��9�G•�C.U� V"� Cat Testallo. ���� � Date � �� ��
�r�i'UJ6��� � ���
�a�e # �u������
llate last accuracy tested C,Q •�� 'L
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy