2011_0620CfIECI{ ONE:
IRRIGATION DOMESTIC :: FIRELINE
BACKFLOW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The backllow 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
f] Reduced Pressure Principle C Pressure Vacuinn Breaker
� Double Check Valve O Atmosphere Vacuum Breaker
Manufact�er
Model Number
Serial Number
Size
Located At
The above is ccr-afcd to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
�.._. ..
Cert. Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM
BRFAF.'F'R
Double Check Valve Assembly
Ist Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Ininal Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Tight O
Leaked �
psid
osid
RP- osid
Leaked e
Did not Open o
Leaked D
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is ccr-afcd to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
�.._. ..
Cert. Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy