2010_1214Y..
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CIIECK ONE=
IRRIGATION DOMESTIC FIRELIN E
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 Reduced Pressure Principle o Pressurc Vacutnn Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is cerrif ed to be true.
Firm Name
Firm Address
Gauge #
hate 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
BRFaKF'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o•
Opened at
Opened at
vsid
Tight �
Leaked �
psid
osid
RP- nsid
Lcaked o
Did not Open �
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight Q
Opencd at
Opened at
osid
Repair
Tight �
nsid
vsid
RP std
The above is cerrif ed to be true.
Firm Name
Firm Address
Gauge #
hate last accuracy tested
Certified Tester
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy