2011_0708 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAIN'T'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
rc;gulations and is certified to kze operating within acceptable parameters.
TYPE OF ASSEMBLY
Q Reduced Pressure Principle � Pressure Vacutna Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is ceruficd to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No.
Date
White — Customers Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRE_AT�R
Double Check Valve Assembly
1st Chekl:
2nd Cheri:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
nsid
Tight �
Leaked D
psid
nsid
RP- vsid
Lcal:ed o
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opined at
Opined at
nsid
Repair
Tight 0
nsid
vsid
RP sid
The above is ceruficd to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No.
Date
White — Customers Copy Yellow —City Copy Pink — Tester's Copy