2011_0228 (2)CIIECK ONE.
IRRIGATION DOMESTIC FIRELIN E
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERVICE:
The backllow 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 Vactnzm Breaker
t7 Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date -
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL7T_TM
BRRAKFR
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Tight C7
Leaked D
psid
nsid
RP- nsid
Leaked a
Did not Opm o
Leaked D
Rcpaus
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date -
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy