2011_0629CiIECI� ONE=
IRRIGATION
DOMESTIC
FIR E LIN E
BACKFI.OW PREVEN'T'ION 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
� Reduced Pressure Principle a Pressure Vacutnn Breaker
a Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Fitm Namc
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester '"
Cent Tester No. Date
White — Customer's Copy Yellow —City Copy Yiinit — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJLJM
BRE_A�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight n
Opened at
Opened at
nsid
Tight D
Leaked o
psid
nsid
RP- nsid
Leaked �
Did noc Open �
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight C7
Opened at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP std
The above is certified to be true.
Fitm Namc
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester '"
Cent Tester No. Date
White — Customer's Copy Yellow —City Copy Yiinit — Tester's Copy