2011_0217CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW 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 certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle a Pressure Vacutnn Breaker
� � Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer Size
Model IN umber
Serial Number
Located AL -
The above is certified to be true.
Firm Name _ -"yQ � Certified Tester ,. i,'.
Firm Address -<< '( �~ Cert. Tester No. Date
Gauge # 3 � 7 �; �� �.v S(1 At
Date Iast accuracy tested � � — � �(- f (7
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIILTM BR��R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closcd
Closed Tight -Q "
Opened at
Opened at
osid
Tight o
Leaked o
psid
osid
RP- - osid
Lcaked �
Did not Open o
Leaked a
Rep airs
and
Materials
Used
Test Auer
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Repair
Tight a
osid
osid
RP sid
The above is certified to be true.
Firm Name _ -"yQ � Certified Tester ,. i,'.
Firm Address -<< '( �~ Cert. Tester No. Date
Gauge # 3 � 7 �; �� �.v S(1 At
Date Iast accuracy tested � � — � �(- f (7
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy