2011_0620CHECK ONE.
IRRIGATION DOMESTIC �o , FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
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 Rcduccd Pressure Principle � Pressure Vana� Breaker
0 Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
_._ . _. _
The above is certified to be true.
Firm Name
Certified Tester
Firm Address Cert_ Tester No. Date
Gauge #
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJiJM BFLAL'F'R
Double Check Valve Assembly
1st Chekl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight d
Opined at
Opined at
osid
Tight �
Leaked �
psid
osid
RP- osid
Leaked �
Did not Opm �
Leaked C7
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opined at
Opined at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Certified Tester
Firm Address Cert_ Tester No. Date
Gauge #
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy