2011_0506 (3)CHECK ONE_
IRRIGATION DOMESTIC FIRELiN
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERVICE:
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
D Reduced Pressure Principle � Pressure Vacuimm Breaker
�. Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number
Located At
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJLJM BRFAT."FIZ
Double Check Valve Assembly
1st Cher: tad Checl:
Relief Valve
Air Inlet Check Valve
Initial Test
DC- Closed Closed Tight
O Opened at
Opened at nsid
Ti°hL o Leaked
� psid
nsid
RP- nsid
1 -caied �
Did not Open � Leaked o
Repau-s
and
Materials
Used
Test ARer
DC- Closed Closed Tight
o Opened at
Opened at nsid
Repair
Tighi �
nsid
nsid
RP sid
The above is certified
to be true.
Fitm Name
Certified Tester
Firm Address
Cent Tester No.
Date
Gauge #
Date last accuracy tested
White - Customer`s Copy Yellow -City Copy Pink - Tester`s Copy