2011_0628 (2)CIIECK ONE:
IRRIGATION
llOMESTIC
FIRELINE
BACKFLOW 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 VacuL�**+ Breaker
D Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model I�iumber
Serial Number
Size
Located AL
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VAC"ITCTM BRFaKFR
Double Check Valve Assembly
1st Checl: 2nd Chekl: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed
Closed Tight o
Opined at Opined at
nsid
Tilt o
Lcakcd �
psid nsid
RP- nsid
Leaked �
Did not Opm D
Leaked o
�P�s
and
Materials
Used
Test ARer DC- Closed
Closed Tight o
Opined at Opined at
nsid
Repair Tight �
nsid nsid
RP sid
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy