2011_0825CHECK 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
o Reduced Pressure Principle � Pressure Vacua Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true_
Firm Name Certified Tester
Firm Address Cat. Testa No_
Gauge #
Date last accuracy tested
Date ::'
White — Customer's Copy Yellow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaKFR
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Tat
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Tight d
Leaked �
psid
nsid
RP- nsid
Leaked o
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight t7
Opeacd at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true_
Firm Name Certified Tester
Firm Address Cat. Testa No_
Gauge #
Date last accuracy tested
Date ::'
White — Customer's Copy Yellow —City Copy Pink — Testers Copy