2011_0406 (4)CIiECK ONE:
IRRIGATION
i7O IM ESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: = �
The backtlow 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
� Reduc. -d Pressure Principle a Pressure Vacuum Breaker
� Double Check Valve c Atmosphere Vacuum Breaker
Manufacnu er
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tester
Cent Teste No.
Date
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRF AT.'FR
Double Check Valve Assembly
1st Chec4:
Znd Checl:
Relief V aloe
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opened at
Opened at
nsid
Tight o
Leaked O
psid
nsid
RP- psd
Leaked C
Did not Open o
Leaked o
Rep airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight a
Opened at
Opened at
nsid
Repair
Tight Q
psid
nsid
RP std
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tester
Cent Teste No.
Date
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy