2011_0426CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MA.INI'ENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The backtlow prevention assembly detailed below has been tested and maintained as required by TCGQ
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
� Reduced Pressure Principle a Pressure Vacutmm Breaker
n Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Modei I�+umber
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Film Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cerc. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREr1E�R
Double Check Valve Assembly
1st Checl:
tad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
osid
Ti�ht�,�?" Cl
Leaked -'' o
psid
o_ sid
RP- osid
Leaked ' a
Did not Opm a
Leaked o
Repairs
and
,-
Materials
Used
Test Altar
DC- Closed
Closed Tight o
Opined at
Opined at
Dsid
Repair
Tight o
osid
osid
RP a sid
The above is certified to be true.
Firm Name
Film Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cerc. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy