2011_0426CHECK ONE.
IRRIGATION DOMESTIC FIR ELIN
BACKF'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS.
PWS_ I_D. #
LOCATION OF SERVICE:
The backllow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certited to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle a Pressure Vacutmm Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Modes Number
Serial Number
Size
_._ _.
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJLTM BRE_A�'�'R
Double Check Valve Assembly
1st Chek:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight C]
Opened at
Opened at
osid
Tight o
Leaked �
psid
osid
RP- nsid
Leaked C7
Did not Opea O
Leaked �
Rtpairs
and
Materials
Used
Test Auer
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
nsid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy