2011_0117CHECK ONE:
IRRIGATION DOMESTIC FIR E LYN E
BACKFT.OW 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
� Reduced Pressure Principle D Pressure Vacuum Breaker
�'" Double Check Valve o Atmosphere Vacuum Breaker
Manufacttffer Size
Model Number
Serial Nammber
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
_ Certified Tester
Cart Teste No.
Dace
White - Customer's Copy Yellow -City Copy PinK - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'FR
Double Cheek Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Tight -fl
Leaked D
psid
vsid
RP- trsid
Leaked o
Did not Open o
Leaked o
�Paix's
and
Materials
Used
Test Agar
DC- Closed
Closed Tight �
Opened at
Opened at
vsid
Repair
Tight a
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
_ Certified Tester
Cart Teste No.
Dace
White - Customer's Copy Yellow -City Copy PinK - Tester's Copy