2011_0506 (5)CFIECK ONEc
IRRIGATION DOMESTIC. FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE 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 Reduced Pressure Principle O Pressure Vacutnn Breaker
fl Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is cetti£ed to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
.._ =Y—
Cent. Tester No.
Date
White — Customers Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_�►�'R
Double Check Valve Assembly
1st Checl: 2nd Cbecl: Relief Valve
Air Inlet Check Valve
Initial Test
DC- Closed Closed Tigh[ p Opined at
Opined at
nsid
Tight 7 Leaked - � psid
nsid
RP- nsid
Leaked D
Did not Opm �
Leaked o
Rap airs
and
Materials
Used
Test After
DC- Closed Closed Tight o Opined at
Opined at
nsid
Rapair
Tight � nsid
nsid
RP std
The above is cetti£ed to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
.._ =Y—
Cent. Tester No.
Date
White — Customers Copy Yellow —City Copy Pink — Tester's Copy