2011_0520CIIECK ONE:
IRRIGATION �; - DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � � � �� %
PWS I_D. #
LOCATION OF SERVICE: % - - i - i -
"The backtlow 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
� Reduces -d Pressure Principle � Pressure Vaccnmm Breaker
rt� Double Check Valve � Atmosphere Vacuum Breaker
� ,:�.
Manufacturer /` - - � - Size
Model Number Located At � �' r �, } �� �" �� � /"
Serial Number �/ 1 - ✓ <- -
The above is certified to be true_
Firm Name - � , � • ^
Firm Address �; - f 1 _> <.
- '� - -
-� -
._ , -
Date last accuracy tested _ '' ;'
Certified Tester 1 ` ' � � '; ,
Cent Tester No. � - Date �_
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRE_AR'F'R
Double Check Valve Assembly
1st Chec1+
�nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Tilt D
Leaked O
psid
osid
RP -��' i psid
�_ �
,�
Leaked �
Did not Opm �
Leaked �
Rcpau-s
and
Materials
Used
Test ARer
DC- Closed
Closed Tieht o
Opined at
Opined at
osid
Repair
Tigltt �
nsid
osid
RP sid
The above is certified to be true_
Firm Name - � , � • ^
Firm Address �; - f 1 _> <.
- '� - -
-� -
._ , -
Date last accuracy tested _ '' ;'
Certified Tester 1 ` ' � � '; ,
Cent Tester No. � - Date �_
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy