2011_0815CIIECK 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 certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
a Reduc. -d Pressure Principle a Pressure Va�-v>�*+ Breaker
o Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �. .� � 1 i-�. Size
Model Number _J -� � Located At �
Serial Number f'F � � � LL.. %f
The above is certified to be true.
Firm Name Certified Toter _
Firm Address Cent. Tester No. Date
Gauge #
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAR'�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[ [3
Opined at
Opined at
nsid
Tilt o
Leaked o
psid
nsid
RP- nsid
Leaked o
Did not Opm �
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight [7
nsid
nsid
RP sid
The above is certified to be true.
Firm Name Certified Toter _
Firm Address Cent. Tester No. Date
Gauge #
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Testers Copy