2011_0620 (4)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACT{FI.OW 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 certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
D Reduc,. -d Pressure Princin_ le C Pressure Vacuum Breaker
D Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located Ai
The above is cctYifed to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No_
Date
White - Customer's Copy Yellow -City Copy PinK - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEi�iBLY
I PRESSURE VACL7LTM 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
nsid
Tight o
Leaked �
psid
nsid
RP- nsid
Leaked o
Did not Open o
Leaked o
Rep airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight D
Opened at
Opened at
nsid
Repair
Tight 0
nsid
nsid
RP sid
The above is cctYifed to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No_
Date
White - Customer's Copy Yellow -City Copy PinK - Testers Copy