2011_0107 (4)CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY 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 certiYied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle D Pressure Va�-ut*?+ Breaker
n Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is cctified to be true.
Firm Name
Firm Address
Gauge #
llate Iast accuracy tested
Certified Tester
Cert. Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUiTM BRF_AKER
Double Check Valve Assembly
1st Chec3:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[ C7"
Opened at
Opened at
osid
Tilt [3"
Leaked o
gsid
osid
RP- osid
Leaked o
Did not Oprn o
Leaked o
Rtpairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tight O
osid
osid
RP sid
The above is cctified to be true.
Firm Name
Firm Address
Gauge #
llate Iast accuracy tested
Certified Tester
Cert. Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy