2011_0628 (6)CIIECK ONEc
IRRIGATION
ll O M ESTIC
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 ❑ Pressure Vag -.nnn Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Serial Number
Size
Located At
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL7L7M SRFaKFR
Double Check Valve Assembly
1st Checl: 2nd Check Relief Valve
Air Inlet
Check Valve
Initial Test DC- Closed
Closed Tight ❑
Opined at
Opined at
nsid
Ti°bt ❑
Leaked O
psid
__psid
RP- osid
Leaked ❑
Did noc Opm ❑
Leaked ❑
Repairs
and
Materials
Used
Test ARer DC- Closed
Closed Tight ❑
Opined at
Opined at
osid
Repair Tight �
vsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Ccrt Tester No.
Date
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy