2011_0629CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
_ BACT�'I.OW PREVENTION ASSEA�LY TEST AND MAINTENANC.� REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backllow 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 Reduced Pressure Principle � Pressure Va�-u� Breaker
o Double Check Valve � Atmosphere Vacuum Breaker
Manufacttzrer Size
Model Number Located AL
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester _
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLTLTM
BFZFAKF'R
Double Check Valve Assembly
1st Chekl:
tad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 0
Opined at
Opened at
vsid
Tight o
Leaked o
psid
vsid
RP- vsid
Leafed o
Did not Opm o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight t7
vsid
vsid
RP std
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester _
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy