2011_0413 (2)CIIECK ONE:
IRRIGATION DOMESTIC
FI RELINE
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
� Reduced Pressure Principle D Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Ntmmber
Size
Located At
The above is certified to be true_
Firm Name
Firm Address --
Gauge #
Date last accuracy tested
Certified Tester
Ccrt_ Tester No_
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaI.'FR
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
psid
Tight ['�
Leaked �
psid
vsid
RP- Dsid
Lcal:ed a
Did not Opm D
Leaked o
�P��
and
Materials
Used
Test After
DC- Closed
Closed Tight t7
Opined at
Opined at
psid
Repair
Tight o
trsid
psid
RP std
The above is certified to be true_
Firm Name
Firm Address --
Gauge #
Date last accuracy tested
Certified Tester
Ccrt_ Tester No_
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy