2011_1005 (5)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACi�T.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I -D. #
LOCATION OF SERVICE:
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certited to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o _ Reduc�i Pressure Principle o Pressure Vacuum Breaker
�� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer "
Model Number
Serial Number
Ssze
Located At -,
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_�►��R
Double Check Valve Assembly
1st Check 2nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test DC- Closed
Closed Tight t3 "
Opened at
Opened at
nsid
Tight o'
Leaked o
psid
nsid
RP- nsid
Lcaiced �
Did not Open O
Leaked o
Repairs
and
Materials
Used
Test ARPT DC- Closed
Closed Tight o
OpCIICd at
Opened at
nsid
Repair Tight o
nsid
nsid
RP sid
The above is certified to be ttue-
Firm Name -
Firm Address _ - _ _ _ -
Gauge #
Date last accuracy tested
Certified Tester ='��
Cent_ Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy