2011_0412CHECK ONE:
IRRIGATION_ DOMESTIC
FIRE LIN 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 o Pressure Vacuimm Breaker
p-= -" _ Double Check Valve � Atmosphere Vacuum Breaker
Manufacz�ser - Size
Model Number ij ;" ' _ . `_= Located At
Serial Number �. i � � ' "
The above is certified to be true. � ,/�
Firm Nano t� y l �" i' �.� �' -�-" � Certified Tester t � '� " t
Firm Address 3 ��'' � ` ` " = � ~ �� Cert Tester No. � '- _.,: _ � Date � -�
Gauge # � � C � � L'�3 Q Q�-a
Date Iast accuracy tested � Z— � � �'� � D
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJLIM BRF'A�'R
Double Check Valve Assembly
1st Cher1:
Znd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight E7
Opened at
Opened at
osid
Ti°bt._, -
Leaked o
psid
osid
RP- '� } osid
Leaked o
�/l
Did not Open o
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opened at
Opened at
osid
Repair
Tight �
osid
osid
RP std
The above is certified to be true. � ,/�
Firm Nano t� y l �" i' �.� �' -�-" � Certified Tester t � '� " t
Firm Address 3 ��'' � ` ` " = � ~ �� Cert Tester No. � '- _.,: _ � Date � -�
Gauge # � � C � � L'�3 Q Q�-a
Date Iast accuracy tested � Z— � � �'� � D
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy