2011_0620 (8)CHECK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACI�'I.OW PREVEN'T'ION 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 certified to he operating within acceptable parameters.
TYPE OF ASSEl��ffiLY
C� Reduced Pressure Principle C Pressure Vacutnn Breaker
O Double Check Valve C E1,tmosphei-e Vacuum Breaker
Manufacturer S
Model Number
Sepal Number
ize
Located At
The above is cc:-afed to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJiTM SRFa>;'FR
Double Check Valve Assembly
1st Chek1:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Tcst
DC- Closed
Closed Tight �
Opezeed at
Opened at
osid
Ti�bt D
Leaked o
psid
osid
RP- osid
Leaked G
Did not Open O
Leaked O
Rcp airs
and
Materials
Used
Test Auer
DC- Closed
Closed Tight D
Opened at
Opined at
osid
Repair
Tight o
osid
osid
RP sid
The above is cc:-afed to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy