2011_0708 (2)CIIECK ONE_
IRRIGATION
DOMESTIC
FIRELIN E
BACKFT.OW PREVEN'T'ION ASSEMBLY TEST AND MAI1V'I'ENANCE 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
Q Reduc�i Pressure Principle a � Pressure Va�-+++�**+ Breaker
�, Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true_
Firm Namc
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRE_A�'R
Double Check Valve Assembly
1st Check
?nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight d
Opened at
Opened at
nsid
Tight �
Leaked o
psid
nsid
RP- nsid
Leaked �
Did noc Open O
Leaked 0
Repairs
and
Materials
Used
Test Aftrs
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true_
Firm Namc
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy