2011_0620 (5)CHECK ONE:
IRRIGATION llO MIESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAIlVI'ENANCE 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 certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacui� Breaker
� Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certif � to be true_
Firm Name
Firm Address
Gauge #
bate last accuracy tested
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM BRF 47� -F'R
Double Check Valve Assembly
1st Chet:
?nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
psid
Ti°laL o
Leaked �
psid
psid
RP- pSld
Leaked o
Did not Open o
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opened at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is certif � to be true_
Firm Name
Firm Address
Gauge #
bate last accuracy tested
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy