2011_0517CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: /
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
❑
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Ann sphere Vacuum Breaker
Manufacturer
` �_% Size
T—
Model Number 5Z) Located At
Serial Number tI 1&,q 98
The above is certified to be true. LZ ia 1244V V/ Certified Tester
Firm Name �
n
Firm Address yi) C L- F-Z1` Cert. Tester No. 1S Date
Gauge # P
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
psid
Tigh� ar
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true. LZ ia 1244V V/ Certified Tester
Firm Name �
n
Firm Address yi) C L- F-Z1` Cert. Tester No. 1S Date
Gauge # P
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy