2011_0506 (2)CPTECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFT.,OW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
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
o Reduces Pressure Principle O Pressure Vacuum Breaker
[1 Double Check Valve O Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Serial Number
Size
Located AL
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRt± aKFR
Double Check Valve Assembly
1st Chec1: 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed
Closed Tight Q
Opened at Opened at
nsid
Tight �
Leaked �
psid nsid
RP- nsid
Leaked o
Did not Open o
Leaked o
�P��
and
Mataials
Used
Test Aficr DC- Closed
Closed Tight o
Opened at Opened at
nsid
Repair Tight o
nsid nsid
RP sid
The above is certified to be trot.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy