2011_0107 (3)CIIECK ONE.
IRRIGATION llOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEA�LY TEST AND MAINTENANCE 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
� Reduces Pressure Principle � Pressurc Vane**+ Breaker
C�-�' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Serial Number
Located At - "
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tester
Cert. Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFLFAS.'�'R
Double Check Valve Assembly
1st Chekl:
?nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight Q-"
Opened at
Opened at
vsid
Tilt E3"
Leaked a
psid
vsid
RP- vsid
Lccied o
Did not Opea o
Lcal:cd 4
Rcpaus
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opcaed at
vsid
Repair
Tight �
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tester
Cert. Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy