2011_0228CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW 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
Q Reduces Pressure Principle o Pressure Va�-u� Breaker
L3_ Double Chxk Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is ceraificd to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No.
Date
White — Customer`s Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRFaxF'R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight [7
Opened at
Opened at
nsid
Tight �
Leaked �
psid
nsid
RP- nsid
Leaked D
Did not Open o
Leaked o
Rcp airs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP std
The above is ceraificd to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No.
Date
White — Customer`s Copy Yellow —City Copy Pink — Tester's Copy