2011_1005 (4)CHECK ONE:
IRRIGATION llOMESTIC FIRELINE 4.
BACKF'I.OW PREVENTION ASSEMBLY TEST AND MpiINI'ENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE: <.. --
The backilow 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 o Pressure Va�-u� Breaker
[�- Double Check Valve � Atmosphere Vacuum Breaker
9
Manufact�er Size �-'/ �1
Modei Number a'' • Located AL => t C� � .t.�v . � � � o � i -fit �
Serial Number
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
llate last accuracy tested
Certified Tester - - -
Cent Tester No. � i Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA��R
Double Check Valve Assembly
1st Cheri:
2nd Cbeci:
Reiief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight G3'
Opened at
Opened at
nsid
Ti�at C°3'
Leaked �
psid
nsid
RP- nsid
Leaked a
Did not Oprn o
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight t7
nsid
nsid
RP std
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
llate last accuracy tested
Certified Tester - - -
Cent Tester No. � i Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy