2011_0105 (2)CHECK ONE-
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERVICE_ � r'
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 Pressure Va�-u� Breaker
;� Double Check Valve, ; __ - o Attnosph___ °`��- ------ Breaker
Manufacturer Size -
Model Number Located AL _ .
Serial Number
The about is certified to be true.
Firm Namc /�+.
Firm Addrzs_s
Gauge #
Date last accuracy tested
Certified Tester _ ,', i . ;
Cent. Testa No. Date r i
White - Customers Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaKFR
Double Check Valve Assembly
1st Chek1:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opined at
nsid
Tight a
RP- nsid
Leaked D
psid
_nsid
`��
Leaked D
Did not Opm D
Leaked a
Repairs
and
Materials
Used
Test ARa
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Repair
Tight [7
nsid
nsid
RP sid
The about is certified to be true.
Firm Namc /�+.
Firm Addrzs_s
Gauge #
Date last accuracy tested
Certified Tester _ ,', i . ;
Cent. Testa No. Date r i
White - Customers Copy Yellow -City Copy Pink - Tester's Copy