2011_0726 (2)CIIECI^� ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: '
The bacl<tlow 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 Varut**n Breaker
O Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer �� Size
Model Number
Serial Number
Located At
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester _
Cert. Tester No:
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaT.'FR
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
vsid
Tight ��
Leaked �
psid
osid
RP- _:'vsid
Leaked o
Did not Open o
Leaked o
�P��
and
MatnriaLs
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight Q
osid
osid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester _
Cert. Tester No:
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy