2011_0107CHECK ONE:
IRRIGATION
DOMESTIC
FIRELIN E
BACKFT.OW PREVENTION ASSEA�LY TEST AND MA7iV'I'ENANCE REPORT
NAivIE OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TCGQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle a Pressure Vacuum Breaker
� Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer
Modei IV umber
Serial Number
Size
Located At
The above is cct-tified to be true_
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No.
Dasc
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM SRE_A�'F'R
Double Check Valve Assembly
1st Chek:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight Q-
'Opined at
Opined at
nsid
Tight C3'"
Leaked �
psid
nsid
RP- nsid
LcaIced o
Did not Opm o
Leaked 4
RePaire
and
Materials
Used
Test Af%er
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight D
nsid
vsid
RP sid
The above is cct-tified to be true_
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No.
Dasc
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy