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CtIECK ONE:
IRRIGATION DOMESTIC FIRELINE
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BACIC�'LOW PREVENTION ASSEII�LY TEST AND MAINTENANCE REPORT
NAN�OF PWS: � C' T l.J�a,�_hc� V SP
PWS I.D. #
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LOCATION OF SERVICE: �� �5 G'rf�-d-c-V t e..�J `31.�� .C��"� 7�d /�
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parame[ers.
TYPE OF ASSEMBLY
❑ Reducrd Pressure Principle ❑ Pressurc Vacu�Breaker
�, Dauble Check Valve � A�nosphere Vacuum Brealer
Manufacrurer �w�► � �N.1S $iu � ~
Modei Ivumbcr �5O �b Locaud At �u1� (c����d'�Oq�h
s�►�N�b� �� 7 8 3
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubf�Checic Valve Assembly
lst Check 2nd Checl: Relief�alve Air Inl�t Check Valve
Iniaal Test DGClosed Closed Ti;ht � Opened at Opcned at nsid
Ti�t � Leal:ed 0 psid osid
� RP-o���Dsid a ,a,
�;� ❑ Did not Opea o Leal:ed �
�P�
and
Materials
Used
Test After DGClosed Closed Tight ❑ Opeaed at Openod at osid
Repair Tight ❑ �sid osid
RP sid
The above is certifiod to be true.
Firm Name Y 1 Ccrtifiod Testa /1 r-�� k��
Fi�Address�� r��-4-►�� V�uJ L�( Cerc. Tester No.�[x.�3�3/ Date � /
Q�`� Ty T�.t�/s�
(��uge # �07 6 7A�/
llate last accuracy tested '7 $ /
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy