2011_0330CIIECI� ONE.
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION 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 be operating within acceptable parameters.
TYPE OF ASSEMBLY
O Reduced Pressure Princivle o Pressure Va�-u� Breaker
O Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is certified to be true.
Firm Name
Firm Address ;'
Gauge #
Date Iast accuracy tested
Certified Testa
Cent Tester No:" Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAG'iJLTM BRE_A�R
Double Check Valve Assembly
1st Chec1:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Tilt D
Leaked Q
psid
vsid
RP- psid
Leaked �
Did not Open o
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight a;
Opened at
Opened at
vsid
Repair
Tight o
�
nsid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Address ;'
Gauge #
Date Iast accuracy tested
Certified Testa
Cent Tester No:" Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy