2011_0707CIIECI� ONE:
IRRIGATION
DOMESTIC
FIR E LIN E
BACKFi.OW PREVENTION ASSEI��LY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D_ #
LOCATION OF SERVICE: � + `.-
The backtlow 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 Reduced Pressure Principle o Pressure Vacuum Breaker
D Double Check Valve � Atmosphere Vacuum Breaker
Manufacreser Size
Model Number Located At �-
Serial Number
The above is ceitii -ed to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No.
_�;= � e•
° Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A►R'�'R
Double Chec3c Valve Assembly
1st Chec3:
Znd Chec1:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight Q
Opined at
Opined at
vsid
Tight . 9
Leaked a
psid
osid
RP- osid
Leaked o
Did not Open �
Leaked 0
Repaus
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is ceitii -ed to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No.
_�;= � e•
° Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy