2011_0620 (2)CHECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACICFZOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS.
PWS I.D. #
LOCATION OF SERVICE:
The backYlow 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
� Reduced Pressure Principle � Pressure Vacuum Breaker
o Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
<iauge #
Date last accuracy tested
.. _.
Cert. Tester No. _ Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEi�iBLY
PRESSURE VACUUM SRF as.�R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opened at
Opened at
psid
Tight �
Leaked �
psid
psid
RP- psid
Leaked a
Did not Open o
Leaked o
Rep airs
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 certified to be true.
Firm Name
Firm Address
<iauge #
Date last accuracy tested
.. _.
Cert. Tester No. _ Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy