2011_0721 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELIN
BACKF'I.OW PREVENTION ASSEA�LY 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 certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle D Pressure Vacuinn Breaker
D Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Iii 1ffiber
Serial Number
Located At
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRFai,'FR
Double Check Valve Assembly
1st Checl: 2nd C'bed: Relief Valve
Air Inlet
Check Valve
Initial Test DC- Closed
Closed Tight t3-
Opined at
Opined at
osid
Tight. fl
Leaked �
psid
osid
RP- osid
Leaked �
Did not Opm O
Leaked �
Rep airs
and
Materials
Used
Test Afire DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester '
Cent Tester No. _'_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy