2011_1005 (2)CIIECK ONE.
IRRIGATION D0144ESTIC 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 he operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle D PrCSSUrC Va��+***+ Breaker
O - Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester , -
Cent_ Tester No. Date
Waite - Customer *s Copy Yellow -City Copy Pink - Tasters Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJLIM BRE_a�'F'R
Double Check Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight C3=
Opened at
Opened at
nsid
Tilt B"
Leaked a
psid
nsid
RP- nsid
Leaked �
Did not Open o
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester , -
Cent_ Tester No. Date
Waite - Customer *s Copy Yellow -City Copy Pink - Tasters Copy