2011_0630CfIECK ONE:
IRRIGATION DOMESTIC FIRELIN
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
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
a Reduced Pressure Principle � Pressure Va�-u� Breaker
Q Double Check Valve � Atrnospherc Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�F'R
Double Check Valve Assembly
1st Cher1: 2nd Checl Relief Valve Air Inlet Check Valve
Initial Tat DC- Closed Closed Tight D
Opened at Opened at
nsid
Ti�L Q Leaked [7
psid _nsid
RP- nsid
I-ea ced o
Did not Oprn o
Leaked o
Repairs
aad
Materials
Used
Test ARer DC- Closed Closed Tight C7
Opened at Opined at
nsid
Repair Tight C]
nsid nsid
RP sid
The above is certii -ed to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Cent_ Tester No.
Dste
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy