2011_0222CHECK ONE:
IRRIGATION llOMESTIC FIRELINE
BACKFI.OW PREVEN'T'ION ASSEA�LY TEST AND MA71�i'I'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 Vacua Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name __ _
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent_ Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V ACLTLTM BRE_A�R
Double Check Valve Assembly
1st Cher:
2nd Checl:
RelieF Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[ . -r3'"
Opened at
Opined at
vsid
Tight o
Leaked o
psid
vsid
RP- vsid
Leaked o
Did not Opm O
Leaked 0
Repaus
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opmcd at
vsid
Repair
Tight o
osid
vsid
RP std
The above is certified to be true.
Firm Name __ _
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent_ Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy