2011_1102cIIECI� oNE=
IRRIGATION DOMESTIC
FIRELIN E
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE 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
o Reduced Pressure Principle a Pressure Va�-+nn*+ Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
Manufact�ser
Model Number
Serial Number
Size
Located AL
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRE_AL'FR
Double Check Valve Assembly
1st Checl: 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight 0
Opined at Opined at
nsid
Ti�L -_._ Q Leaked o
psid nsid
RP- nsid
Leaked �
Did not Oprn D
Leaked o
Repairs
and
Materials
Used
Test ARer DC- Closed Closed Tight o
Opined at Opined at
nsid
Repair Tight C7
nsid nsid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent. Testa No. " Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy