2010_1018CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACEFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. it
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
❑ _-Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer j�' `C�j Size
Model Number C ° Located At r 7
Serial Number t `
The above is certified to be true.
Firm Name vfL�2 Certified Tester �-'� r2.-)
Firm Address L'\ �- i t �Z y Cert. Tester No. Date
Gauge # l `
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ,,C'
Opened at
Opened at
vsid
Tight
Leaked ❑
psid
vsid
RP -vsid
--,� ;
Z"
Leae ❑
Did not Open ❑
Leaked C3
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Repair
Tight ❑
vsid
vsid
RP sid
The above is certified to be true.
Firm Name vfL�2 Certified Tester �-'� r2.-)
Firm Address L'\ �- i t �Z y Cert. Tester No. Date
Gauge # l `
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy