2011_0406 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIKELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The back Flow 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 Vacutnn Breaker
O Double Check Valve D Atmosphere Vaeuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
C�.'L"�t1C'it'i
Cent Testa No.
_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR��R
Double Check Valve Assembly
1st Cher:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight a
Opened at
Opened at
nsid
Tight C7
Leaked �
psid
nsid
RP- nsid
Leaked o
Did noc Open o
Leaked D
Rapairs
aad
Materials
Used
Test ARrs
DC- Closed
Closed Tight D
Opened at
Opened at
osid
Repair
Tight a
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
C�.'L"�t1C'it'i
Cent Testa No.
_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy