2011_0628 (3)CIIECK ONE:
IRRIGATION DOMESTIC FIR ELIN
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 be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle a Pressure Vacuum Breaker
�? Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Located At
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRT:'AKFR
Double Check Valve Assembly
1st Check tad Checl:
Relief Valve
Air Inlet Check Valve
Initial Test
DC- Closed Closed Tight
� Opined at
Opined at
osid
Ti�bt n Leaked
o psid
osid
RP- osid
I -caked �
Did not Opm o
Leaked 0
Repairs
and
Materials
Used
Test After
DC- Closed Closed Tight
o Opined at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is certified to be true.
Firm Name
Certified Tcstrr
Firm Address
Cent. Testa No.
- - ___ Date
Gauge #
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy