2011_0628 (7)CIIECK ONE_
IRRIGATION DOMESTIC 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 TCGQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduc. -d Pressure Principle O Pressure Vacuimm Breaker
a Double Check Valve C Atmosphere Vacuum Breaker
Manufactan-er Size '
Model Number
Serial Number
Located At
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA��R
Double Check Valve Assembly
1st Chec3: 2nd Checl:
Reiief Valve
Air Inlet
Check Valve
Initial Test DC- Closed
Closed Ti�h[ �
Opened at
Opened at
nsid
Tight Q
Leaked o
psid
__nsid
RP- nsid
Leaked o
Did not Open O
Leaked a
�P��
and
Materials
Used
Test ARer DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
. . _. =Yr
Celt Tester No. Date
Wtdte - Customer's Copy YeIIow -City Copy Pink - Tester's Copy