2011_0427 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIR E LYN E
BACI�T.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE: r
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 � Pressure VacuL***+ Breaker
� Double Checl: Valve o Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address ! ;
Gauge #
Date last accuracy tested
Certified Tester _
Cent Tester No_
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAi.'FR
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
nsid
Tight a
Leaked �
psid
nsid
RP- nsid
Leaked �
Did not Opm o
Leaked o
Repairs
and
Materials
Used
Test Afars
DC- Closed
Closed Tight a
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sad
The above is certified to be true.
Firm Name
Firm Address ! ;
Gauge #
Date last accuracy tested
Certified Tester _
Cent Tester No_
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy