2011_0107 (2)CIIECK ONE.
IRRIGATION DOMESTIC FIRELIN
BACKFLOW PREVENTION ASSEMBLY 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
o Rcducrd Pressure Principle o Pressure Va�-*n�**+ Breaker
a Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Modei Number
Serial Number
Located At
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
llate last accuracy tested
Certified Tester
CerL Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL7L7M BFZFA�'R
Double Check Valve Assembly
1st Cheri:
2nd Cheri:
Reiief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight d
" Opined at
Opened at
nsid
Tight d-
'Leaked o
psid
nsid
RP- nsid
Leaked �
Did nor Opm o
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight 0
nsid
nsid
RP sid
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
llate last accuracy tested
Certified Tester
CerL Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy