2014-1210 (2) C�IECK ONE:
IRR.IGATION� DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ��t � r �I � 1 CQ 5� � N� I ���I 1���
PWS I.D. # � � S D � �
LOCATION OF SERVICE:��Q � - ���o�7�-P ��• �ank(}� �}rY�i�C`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 ASSIIv�LY
❑ Reduced Press�c Pri.nciple ❑ Pressur�Vacu�Breaker
�' Double Check Valve ❑ Atmosphere Vacuum BreaLer
I1�
Manufacturer �C�('_D Siu '
Model Iv�bet ��� Located At �n f v tz n Cz b� /v��.-�-�X
Serial Nimmber �'"��'� �1 CI�3
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubie Check 4alve Assembly
lst Check - � 2 d Checl: 'ef Valve Air Inlet Check Valve
Ininal Test DC-Closed Closed Ti�ht Opened at Opened at nsid
� Tisht / ,�, Leal:e�, -� o _nsid _,_�osid
�� RP-_psid G '
Leal:ed o Did not Opcn O Leal:ed ❑
�P�
and
Materials
Used
Test After DGClosed Closod Tight o Opened at Opeaed at _nsid
Repair 'Tight o _nsid __osid
RP sid
The above is certified to be true.
wdght Bat�low&PLBG b
Firm Name Cettifiod Testa ^O�n N y �A r : �• ��'
Firm Address �''�X 7b150 Ccrt Tester No. �O� 75�Date 7�/����
Gauge # 1 3 '8 p� Z � ��l �t��S �T K � 9 �i E
llate last accuracy tested �0�-�U -j�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy