2011_0426 (3)CIIECK ONE.
IRRIGATION DOMESTIC FIRELIN E
BACKFI.OW PREVENTION ASSE1vIBLY 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
D Reduced Pressure Principle a Pressure Vacuttm Breaker
O Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is certified to be true_
Fitm Name
Fum Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No.
Date
r
White — Customer's Copy YeIIow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Chekl:
2nd Chek1:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight C7
Opined at
Opined at
nsid
Tight E]
Leaked �
psid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked o
�P�
and
Materials
Used
,
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight [7
nsid
nsid
RP sid
The above is certified to be true_
Fitm Name
Fum Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No.
Date
r
White — Customer's Copy YeIIow —City Copy Pink — Testers Copy