2011_0517 (2)CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFT.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 paranuters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle o Pressure Vacua Breaker
Q Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer -` Size
Model Number Located At
Serial Number `
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Tester �� � � �%, Y
Cent. Tester No.�3 P��'�3 � S 2_ nau �—
Wttite - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BFZ_FA►s.'FR
Double Check Valve Assembly
1st Chekl: tad Checl:
Relief Valve
Air Inlet Check Valve
Initial Test
DC- Closed Closed Tight E7 "_
Opened at
Opened at
nsid
Tight o --' 'Leaked o
psid
nsid
RP- - nsid
LcaI:ed C7
Did noc Open o
Locaed o
�P��
and
Materials
Used
Test ARer
DC- Closed Closed Tight o
Opened at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Tester �� � � �%, Y
Cent. Tester No.�3 P��'�3 � S 2_ nau �—
Wttite - Customer's Copy Yellow -City Copy Pink - Testers Copy