2011_0427CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFT.OW 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 TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Presst>re Principle D PKSSUre Va�-ut***+ -+ Breaker
n Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Ntmmber
Size
Located At
?he above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
��.. -•
Cert. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT.'FR
Double Check Valve Assembly
1st Chekl:
2nd Cheri:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Tight !?
Leaked D
psid
osid
RP- osid
Leaked o
Did not Open �
Leaked D
Rep airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight [7
osid
nsid
RP sid
?he above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
��.. -•
Cert. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy