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2011_0506 (4)CtIECK ONE. IRRIGATION DOMESTIC FIRELINE BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAr� OF PWS: PWS I_D_ # LOCATION OF SERVICE: The backl -low 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 Reduced Pressure Principle o Pressurc Va�-+n�**+ Breaker o Double Check Valve � Atmosphere Vacuum Breaker Manufacturer Model Number Serial Number Size Located At The above is testified to be true_ Fiszn Name Firm Address Gauge # Date last accuracy tested Certified Tester Cer[. Tester No_ Date White - Customer's Copy Yellow -City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BR1G'asrF'R Double Check Valve Assembly 1st Chec3: 2nd Cheri: Relief Valve Air Inlet Check Valve Initial Test DC- Closcd Closed Tight © Opcaed at Opened at osid Tight Q Leaked D psid osid RP- osid Lcaked C7 Did nor Open D Leaked a �Paz� and Matesials Used Test Afier DC- Closed Closed Tight D Opened at Opcaod at osid Rcpair Tight � nsid osid RP sid The above is testified to be true_ Fiszn Name Firm Address Gauge # Date last accuracy tested Certified Tester Cer[. Tester No_ Date White - Customer's Copy Yellow -City Copy Pink - Tester's Copy