2014-0612 (5) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAC�I,OW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPORT
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NAME OF PWS: l�\VI u� ��P�l �.�
PWS I.D. # � �� �J
LOCATION OF SERVICE: �O� �� ���11 U T(J�-IP
The backfilow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certitied to be operating within acceptable para»leters.
TYPE OF ASSEMBLY
� Reduc�Pressure Principlc ❑ Pressure Vacu�Brcaker
Double Check Valve ❑ Atmosphere Vacuum Breal:et
Maaufact�er
��S Sizc ��l
Model Nimmber l_/U\� �v Locaud At ��� ����
Scrial N�ber � 1 � � V��v
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doub(e C3eck Valve Assembly
lst Check 2nd Chec3: Relief Valve Air Inlet Check Valve
Iainal Test DGClosed losed Ti;ht Opened at Opened at nsid
�r,�� Ti��sid Leal:� ` ❑ psid osid
��� RP- � �
Leal:ed � Did not Opea � L.eal:ed �
�P�
and
Materials
Uscd
Test After DGClosed Closed Tight o Opmed at Opcned at osid
Rtpair Tight o nsid nsid
RP sid
The above is certifiod to be true.
Firm Name I 1�l ��� Certifiad Testa I�1�t� W V�LI,`�I
Firm Address `�`� � . v���"• Cert. Testa Na � �1 Date °l�3
1����,� 1�
Gauge # b�(�1�1Q g
llate last accuracy tested �.�� '
White - Customer's Copy Yellow - City Copy Pink- Tester's Copy