2011_0708 (6)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELIN E
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 TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle � Pressure Vacua Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
. . � . i �.
Cent Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM SR��R
Double Check Valve Assembly
1st Cheri:
2nd Cbecl.
RelieF Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Tilt �
Leaked 0
psid
nsid
RP- nsid
Leaked Q
Did not Oprn o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
. . � . i �.
Cent Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy