2011_0517CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The backllow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certited to he operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle a Pressurc Va�-u� Breaker
o Double Chcck Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRE_�►�'R
Double Cheek Valve Assembly
1st Checl: 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC- Closed
Closed Tight Z1
Opined at Opened at
osid
Ti�iL �
Lccaed D
psid osid
RP- osid
Leaked C7
Did noc Opm o
Leaked �
Repairs
and
Materials
Used
Test Auer DC- Closed
Closed Tight o
Opined at Opined at
osid
Repair Tight D
osid osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
.. _. _1 _.
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy