2011_0628 (4)CHECK ONE.
IRRIGATION DOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAI1N'I'ENANCE 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 certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Rcduc�i Pressure Principle � Pressure Vacutmm Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRFA►t,'F'R
Double Check Valve Assembly
1st Checl: 2nd Chec3: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight � Opined at Opined at nsid
Tight b Leaked a psid nsid
RP- nsid
Leaked � Did not Opm o Leaked a
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight t7 Opined at Opined at nsid
Repair Tigltt D nsid vsid
RP sid
The above is ce:-aificd to be true.
Firm Name Certified Tester
Firm Address Cert. Tester No. Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy