2011_0413 (4)CfIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D_ #
LOCATION OF SERVICE=
'i "he backYlow prevention assembly detailed below has been tested and maintained as required by TCCQ
regulations and is certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
D - Reduced Pressure Principle D Pressure Vacutnn Breaker
Double Cheek Valve o Atmosphere Vacuum Breaker
i
Manufaczitrer _ Size _ _
Modell�iumber ��
Sepal Number
Located AL .�,,, 4 <`�
J
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Cetified Tester ,
Cent Tester No. ��. Date � `�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRFaKF'R
Double Check Valve Assembly
1st Chec3:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight � ""
Opined at
Opined at
nsid
Ti°hL 0
Leaked o
psid
nsid
RP- vsid
Leaked D
Did not Opm O
Leaked o
Repairs
and
Materials
Used
Test Agar
DC- Closed
Closed Tight o
Opmcd at
Opined at
nsid
Repair
Tight o
vsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Cetified Tester ,
Cent Tester No. ��. Date � `�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy