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2011_0402
CHECK ONE: IRRIGATION DOMESTIC FIRELYNE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # LOCATION OF SERVICE: The backtic�w prevention assembly detailed below has been tested and maintained as required by TCEQ regulations and is certi {ied to be operaCing within acceptable parameters. TYPE OF ASSEMBLY o Reduced Pressure Principle a Pressure Vac-u� Breaker a Double Check Valve o Atmosphere Vacuum Breaker Manufacturer Size Model Number Located At Serial Number The above is cea-tifed to be true. Firm Name Firm Address Gauge # Date last accuracy tested Certified Tester Cent Tester No. - ___ Date White — Customer's Copy Yellow —City Copy Pink — Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRE_A�'R Double Cherlc Valve Assembly 1st Checl: Znd Chekl: Relief Valve Air Inlet Check Valve Initial Tat DC- Closed Closed Tight ;© Opined at Opined at vsid Tilt � Leaked � psid vsid RP- vsid Leaked o Did not Oprn o Leaked o �Pa� and MatLrials Used Test Afhrr DC- Closed Closed Tight O Opined at Opined at vsid Repair Tight a vsid vsid RP sid The above is cea-tifed to be true. Firm Name Firm Address Gauge # Date last accuracy tested Certified Tester Cent Tester No. - ___ Date White — Customer's Copy Yellow —City Copy Pink — Tester's Copy