2011_0406 (5)CIIEC�K ONE-
IRRIGATION
ll0 M ESTIC
FIRELIN E
BACKFT.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 certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle D � Pressure Vacutnn Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Ntnnber
Size
Located At
The above is certified to be true_
Firm Name
Firm Address
Gauge #
bate last accuracy tested
Cert. Tester No.
Date
White — Customer's Copy Yellow —City Copy PinK — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSENLBLY
PRESSURE VACUUM BRE_4I{ER
Double Check Valve Assembly
1st Checl:
2nd Chec1:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight C
Opened at
Opened at
osid
Tit C
Leaked C
psid
osid
RP- osid
Leaked C
Did not Open C
Leaked C
Rcp airs
and
Materials
Used
Test ARrr
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight C
osid
osid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
bate last accuracy tested
Cert. Tester No.
Date
White — Customer's Copy Yellow —City Copy PinK — Testers Copy