2011_0406 (3)CiIECK ONE_
IRRIGATION DOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MA.IN'I'ENANCE 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 o Pressure Va�-+nn*+ Breaker
�, Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model lei umber
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Addtzss
Gauge #
Date Iast accuracy tested
Certified Tester
Cent Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAKF'R
Double Check Valve Assembly
1st Check
2nd Chec3:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
vsid
Tight �
Leaked o
psid
vsid
RP- psid
Leaked D
Did not Opm o
Leaked o
Rep airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight o
Dsid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Addtzss
Gauge #
Date Iast accuracy tested
Certified Tester
Cent Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy