2011_1005 (6)CHECK ONE.
IRRIGATION DOMESTIC FIR E LYN
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The back'flow 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 Ptincivle D Pressure Vacuum Breaker
o' Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number � e � Located At :_ d - ;� -
'; .s,,
Serial Number
The above is certified to be true.
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
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFCFAxF'R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight &7'
Opened at
Opened at
osid
Ti�tt �
Leaked 0
psid
osid
RP- -= - osid
,
Leaked o
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test Auer
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight D
Dsid
osid
RP sid
The above is certified to be true.
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