2011_0513CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: A a cj G a A
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer .ice
Model Number
Serial Number l 3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge # 55 (Z 6 57
Date last accuracy tested
Certified Testa
Cert. Tester No. 'J �'v 1 L Date 5�
/L —(C( 4j7
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
Opened at
Opened at
pSid
Tight
RP -�sid
Lea; ❑
Leaked ❑
psid
oSid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
osid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # 55 (Z 6 57
Date last accuracy tested
Certified Testa
Cert. Tester No. 'J �'v 1 L Date 5�
/L —(C( 4j7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy