2011_0426 (5)CIIECK ONE=
IRRIGATION DOfMESTIC
FIRELIN
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE=
The backt7ow 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 O Pressure Vacuum Breaker
O Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Sepal Number
Size
Located AL
The above is caafied to be true_
Firm Namc
Firm Address
Gauge #
Date Last accuracy tested
Cent Testa No.
Date
White - Customer's Copy Yellow -City Copy PinK - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEriIBLY
PRESSURE VACUUM BRF' aR'FR
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tigbt D
Opened at
Opened at
vsid
Tit �
Leaked o
psid
vsid
RP- vsid
Leaked o
Did not Open o
Leaked o
Rcp airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight �
Opened at
Opined at
vsid
Repair
Tight �
vsid
vsid
RP sid
The above is caafied to be true_
Firm Namc
Firm Address
Gauge #
Date Last accuracy tested
Cent Testa No.
Date
White - Customer's Copy Yellow -City Copy PinK - Tester's Copy