2011_0426 (2)CIIECII; ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # _
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TCFQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle D Pressure Vacucnn Breaker
O Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
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 V ACL7UM BRE_A�'R
Double Check Valve Assembly
1st Chekl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight n
Opened at
Opened at
osid
Tilt CI
Leaked �
psid
osid
RP- osid
Leaked o
Did noc Open D
Leaked o
Repairs
and
Materials
Used
Test Ai%er
DC- Closed
Closed Tight D
Opened at
Opened at
osid
Repair
Tight �
osid
osid
RP sid
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