2011_0620 (6)CHECK ONE_
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE 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
D Reduc�ccd Pressure Principle D Pressure Vacuum Breaker
�7 Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
_•_ _ =• _
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
�.r.:C- �:i- IP'iT7
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy PinK — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE:�iBLY
PRESSURE VACUUM SRFAI.'F'R
Double Check Valve Assembly
1st Check
2nd Chec4:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Tit o
Leaked O
psid
osid
RP- osid
Leaked o
Did not Open o
Leaked o
Rcp airs
and
Materials
Used
Test After
DC- Closed
Closed Tighe �
Opened at
Opened a[
osid
Repair
Tight Q
osid
osid
RP rid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
�.r.:C- �:i- IP'iT7
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy PinK — Tester's Copy