2011_0630 (3)CIIECK ONE.
IRRIGATION DOMESTIC FIKELINE
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 Varu� Breaker
R Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI.TCTM BRFAKF'R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight to
Opened at
Opeaed at
osid
Tight o
Leaked D
psid
osid
RP- osid
Leaked o
Did not Open a
Leaked o
Rep airs
and
Materials
Used
Test Afire
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy