2011_0728CHECK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACKFI.OW 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 TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
O Reduced Pressure Principle � Pressure VaeuL�*+ Breaker
O Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
._ _�.
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Testa
Cent Testa No.
Dau
Wtute — Customer's Copy Yellow —City Copy PinK — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFax'FR
Double Check Valve Assembly
1st Chekl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight O
Lcaled C7
psid
osid
RP- osid
Leaked o
Did not Open D
Leaked D
�P��
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight t7
osid
osid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Testa
Cent Testa No.
Dau
Wtute — Customer's Copy Yellow —City Copy PinK — Tester's Copy