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2011_0708 (4)
CHECK ONE= IRRIGATION DOMESTIC FIRELINE BACKFI.OW 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 TCGQ regulations and is certified to be operating within acceptable parameters - TYPE OF ASSEMBLY ❑ Reduc -d Pressure Principle ❑ Pressure Vacutmm Breaker D Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacturer Model Number Serial Number Size Located At REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRF— Af►'FR Double Check Valve Assembly 1st Checl: 2nd Check Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight © Opined at Opined at vsid Tilt ❑ Lccaed ❑ psid vsid RP- vsid Leaked ❑ Did not Opm ❑ Leaked ❑ Repairs and Materials LJs«i ' Test ARer DC- Closed Closed Tight ❑ Opmcd at Opined at vsid Repair Tight ❑ vsid vsid RP sid The above is certified to be true. Firm Name Firm Address Gauge # Date last accuracy tested Certified Tester Cert Testa No. Date White — Customer's Copy Yellow —City Copy Pink — Tester's Copy