2011_0506CFIECI� ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAI1V'I'ENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
a Reduced Pressure Principle D Pressure Vacuum Breaker
-L7 Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Serial Number
Size
Located AL
The above is certified to be true.
Firm Name
Firm Addtzss
Gauge #
Date Yast accuracy tested
Certified Tester
CerL Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA�'R
Double Check Valve Assembly
1st Checl: tad Check: Relief Valve
Air Inlet Check Valve
Initial Test
DC- Closed Closed Tight n Opined at
Opined at
psid
Tight fl Lcal:ed _ � psid
� sid
RP- psid
Lcaaed o
Did not Opm o
Leaked o
Repaus
and
Materials
Used
Test After
DC- Closed Closed Tight � Opined at
Opined at
psid
Repair
Tight o psid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Addtzss
Gauge #
Date Yast accuracy tested
Certified Tester
CerL Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy