2011_0531 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to he operating within acceptable par�u»eters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle a Pressure Va�-u� Breaker
o Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Serial Number
Located AL
The above is certified to be true.
Firm Name > l / i��s' � "� �` i Certified Tester
Firm Address ? � ' _ �t'� � �'` CerL Tester No.
Gauge # � r d �� / �j
Date Iast accuracy tested � � ' �� �
Date
White — Customer's Copy Ye11ow —City Copy Pink — Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFL_A�'F'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[ �-
Opined at
Opined at
osid
Tilt 6
Leaked o
psid
osid
RP- osid
Leaked �
Did not Opm �
Leaked o
Pairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
Dsid
Rapair
Tight �
osid
osid
RP rid
The above is certified to be true.
Firm Name > l / i��s' � "� �` i Certified Tester
Firm Address ? � ' _ �t'� � �'` CerL Tester No.
Gauge # � r d �� / �j
Date Iast accuracy tested � � ' �� �
Date
White — Customer's Copy Ye11ow —City Copy Pink — Tester`s Copy