2011_0630 (2)CIIECiK ONE:
IRRIGATION
DOMESTIC
FIRELIN
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 TCCQ
regulations and is certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
O Reduced Pressure Principle D Pressure Va�-*n•**+ Breaker
�' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located Ai
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACL.TCTM BRFA�R
Double Check Valve Assembly
1st Check 2nd Chec3:
Relief Valve Air Inlet
Check Valve
Initial Tat DC- Closed
Closed Tight o-
Opmcd at Opined at
nsid
Tight C3
Leaked �
psid osid
RP- osid
Leaked �
Did not Opm o
Leaked o
Rep airs
and
Materials
Used
Tat Agar DC- Closed
Closed Tight o
Opined at Opined at
nsid
Repair Tight o
nsid osid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent. Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy