2011_0524 (2)CfIECI{ ONE:
IRRIGATION DOMESTIC FIRELIN E
BACKFLOW PREVENTION ASSE1vIBLY TEST AND MAiN'I'ENANCE REPORT
NAI�� OF PWS:
PWS I_D. #
LOCATION OF SERVICE: -
The backtlow prevention assembly detailed below has been Vested and maintained as required by TCEQ
regulations and is certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
a JR.educ. -d Pressure Principle o Pressure Vactttmm Breaker
�n-�' ` -� Double Check Valve C7 Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address --
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Tester
Cent Tester No. Date
Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Checl:
2nd Chec1:
Refief Valve
Air Inlet
Check Valve
Initial Tcst
DC- Closed
Closed Tight -E1'"
Opened at
Opened at
nsid
Tight_ ., eT�
Leaked o
psid
nsid
RP- F � "� nsid
Leaked �
� , _
Did not Open D
Leaked a
Rcpaus
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opened at
Opened at
nsid
Rtpair
Tight o
nsid
nsid
RP std
The above is certified to be true.
Firm Name
Firm Address --
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Tester
Cent Tester No. Date
Yellow -City Copy Pink - Tester's Copy