2011_1107CiiECK ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVEN'T'ION 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
o Reduc. -d Pressure Princivle � Pressure Vacutmm Breaker
4 Double Check Valve c Atmosphere Vacuum Breaker
Manufacttser Size
Model Number Located At
Serial Ntmiber
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tesur
Cent Testa No. Date T-
White - Customer's Copy Yellow -City Copy PiinK - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJLJM BRFA�'R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opened at
nsid
Tight D
Leaked t7
psid
nsid
RP- nsid
Leaked �
Did aot Opm o
Leaked a
impairs
and
Materials
Used
Test AI%er
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight [7
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tesur
Cent Testa No. Date T-
White - Customer's Copy Yellow -City Copy PiinK - Tester's Copy