2011_0726CfiECK ONE:
IRRIGATION DOMESTIC FIRELIN
BACKFLOW PREVENTION ASSEMBLY TEST AND MALNTENANC� REPORT
NAME OF PWS:
PWS LD. #
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
o Reduced Pressure Principle o Pressure Vain***+ Breaker
li3' "� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number '- l � � � � � ' $
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAF�R
Double Check Valve Assembly
1st Checl: 2nd Cbecl: Refief Valve Air Inlet Check Valve
Initial Test DC- Closed
Closed Tight t3 Opened at Opened at
osid
Ti°hL d
Leaked O psid osid
RP- '" osid
; _'_ < `'�
Leaked C7
Did not Open O
Leaked a
Rep airs
and
Mata-ials
Used
Test Afars DC- Closed
Closed Tight o Opened at Opened at
osid
Repair Tight o
osid osid
RP sad
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa _
Cent. Tester No. _
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy