2011_0412CIIEC,R ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVEN'T'ION ASSEA�LY TEST AND MA.I2�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
o Reduced Pressure Principle o Pressure Vag-+++***+ Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
C ... %l�rt�? -7
Cerc. Testa No.
Date
White — Customer's Copy Ye11ow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAK'E'R
Double Check Valve Assembly
1st Check
2nd Chec1:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Openeri at
Opened at
osid
Tight o
Leaked o
psid
osid
RP- osid
Leaked o
Did not Opea o
Leaked �
RePairc
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
C ... %l�rt�? -7
Cerc. Testa No.
Date
White — Customer's Copy Ye11ow —City Copy Pink — Tester's Copy