2011_0620 (7)CIIECii ONE:
IRRIGATION DOLYIESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D_ i<
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
o Reduc�ccd Pressure Principle O Pressure Vacu33m Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufact7.3rer
Model Number
Serial Number
Size
Located At
The above is ccmfied to be trot_
Firm Name
Firm Addres_s
i3auge #
bate last accuracy tested
Cent. Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSiTRE VACUUM BR>='AT.'FR
Double Check Valve Assembly
1st Checl:
Znd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Tight �
Leaked �
psid
osid
RP- DSId
Leaked o
Did not OPm o
Leaked o
Rep airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is ccmfied to be trot_
Firm Name
Firm Addres_s
i3auge #
bate last accuracy tested
Cent. Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy