2011_0406CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKF'I.OW 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 ceriilied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Q Reduces Pressure Principle � Pressure Vacuum Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be trot_
Firm Name
Firm Address '
Gauge #
Date last accuracy tested
Certified Teste _
Cent Tester No.
Dau
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRFaKF'R
Double Cheek Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight . -C3
Opined at
Opined at
nsid
Tight [7
Leaked a
- - psid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked D
�P�
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP std
The above is certified to be trot_
Firm Name
Firm Address '
Gauge #
Date last accuracy tested
Certified Teste _
Cent Tester No.
Dau
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy