2011_0426 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIR ELIN E
BACKFLOW 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
D Reduced Pressure Principle O Pressure Vacuimm Breaker
o Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert Tests No.'' ij cX�j�S � Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRRas.'FR
Double Check Valve Assembly
1st Chec1:
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight Q
Opened at
Opened at
nsid
Tilt d
Leaked o
psid
nsid
RP- nsid
�
Leaked o
Did not Open D
Leaked o
�P��
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Rrpair
Tight 0
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert Tests No.'' ij cX�j�S � Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy