2011_0714CHECK ONE=
IRRIGATION DOMESTIC FIRELINE
BACi�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backYlow 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
D Reduced Pressure Principle D Pressure Vacua Breaker
LII 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 Tests No.
_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRFaKFR
Double Check Valve Assembly
1st Check
2nd Check
RelieF Valve
?lie Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opened at
osid
Ti°bL [7-
Leaked o
psid
osid
RP- osid
Leaked o
Did not Open �
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opmcd at
Opined at
osid
Repair
Tight a
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tests No.
_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy