2011_0610CIIECK ONE_
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backtlow prevention assembly detailed below has been tested and maintained as required by TCCQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduces Pressure Principle D Pressure Va�-*n�*•+ Breaker
t� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Nrmmber
Size
Located AL
REDUCED PRESSURE P _ S :LTCTM $BEAKER
Double Check Valve Asses � L t-��J � � V
1st Check 2nd C;t � � � � y�� � � � �e� Valve
Initial Test DC- Closed Closed '� � n '� �� nsid
Ti�rL o Leaked 1�
RP- nsid � � T, t- � �'
Leaked o Leaked D
��
and
Materials
Used
Test Aftrs DC- Closed Closed T
Repair Tiglrt o
RP nsid I
The above is certified to be true.
Firm Name Certified Tester
Firm Address Cent Tester No.
Gauge #
Date last accuracy tested
Date
nsid
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy