2011_0708 (3)CIIECi� ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE 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 Vacut>m Breaker
�, Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate Iast accuracy tested
Certified Tester
C�3!�'Ti.[.7
Date
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJCTM BRE_A�'�'R
Double Check Valve Assembly
1st Chekl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight Q
Oprned at
Opened at
nsid
Tight O
Leaked D
psid
nsid
RP- nsid
Leaked �
Did not Open o
Leaked �
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight Q
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate Iast accuracy tested
Certified Tester
C�3!�'Ti.[.7
Date
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy