2011_0510CHECK ONE:
IRRIGATION
DOMESTIC
FIRELYNE
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE= _ __.__
The backflow prevention assembly detailed below has bcen tested and maintained as required by TCEQ
regulations and is certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
D Reduced Pressure Principle D Pressure Vacuum Breaker
n Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name Certified Tester
Firm Address Cert. Tester No. Dau
Gauge #
Date last accuracy tested
White - Customers Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRRaKF'R
Double Check Valve Assembly
1st Chec3:
2nd Cbecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight n
Opened at
Opened at
nsid
Tight D
Leaked �
psid
nsid
RP- osid
Leaked D
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address Cert. Tester No. Dau
Gauge #
Date last accuracy tested
White - Customers Copy Yellow -City Copy Pink - Tester's Copy