2014-0612 (6) ChIECK �NE:
IRRIGATION llOMESTIC FIRELINE
BAC�7.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: .
PWS I.D. # �
�1 ,r� r
LOCATION OF SERVICE: IOO. N • � v+ e�
The backflow prevention assembly detailed below has been tested and maintained as required by T�EQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑/ Reduced Pressure Principle o Pressura Vacuimm Breaker
� Double Chxk Valve o Atmospherc Vacuum Breal:er
Manufactiaer � Size
3 �`'
Model Numbcr Locaud At V�K t't ' �h�� �2V1 �.� 0� J�Jc
Scrial N�bcr �DOlo5 __
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double C3etk V alve Assembly
lst Checl: 2nd Checl: 'ef Valve :�ir Inlet Check Valve
Initial Test DGClosed Closed Ti;ht Opened at Opened at nsid
Ti�f Leal:ed ❑ psid nsid
�y� RP- �1��Dsid � �
� ❑
Lcat;ed ❑ Did noc Open o L,eal;ed
�P�
and
Materials
Uscd
Test After DGClos�d Closed Tight ❑ Opened at Opmed at nsid
Rtpair Tight ❑ osid nsid
R.P sid
The above is ccrtified to be true.
I 1 � �a�
Firm Name l (�.r25� Cerdfi�d Tutc VIM�►�
Firm Address �� ' � Ccrt. Testa No. b����7� Date
�. 1�� ��c�y�:
(�auge # 01QO70�Q�
�ate last accuracy tes�ed
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy