2011_0628 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The back'17ow 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 a Pressttrc Vag -ut>�+ Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BFt��R
Doubie Check Valve Assembly
1st Chec1: 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight ❑ Opened at Opened at nsid
Tilt D Leaked � psid nsid
RP- nsid
Leaked o Did not Open a Leaked Q
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight � Opened aL Opened at nsid
Repair Tight o nsid nsid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address Cent Tester No. ` ' Date
Gauge #
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy