2011_0208CIIECK ONE:
IRRIGATION DOMESTIC FIR E LIN E
BACT�'LOW 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
o Reduced Pressure Principle D Pressure Vac+n•**+ Breaker
n Double Check Valve � Attnospherc Vacuum Breaker
Manufact�ser
Model Number
Serial Number
Size
Located At
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Cetified Tester
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL.TUM BRFaKFR
Double Check Valve Assembly
1st Check
Znd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight n
Leaked o
psid
osid
iz.P- osid
Leaked C7
Did not Open o
Leaked o
�P��
and
Mata-iaLs
Used
Test ARer
DC- Closed
Closed Tight o
Opessed at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Cetified Tester
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy