2011_0426 (6)CIIECK +ONE:
IRRIGATION DOMESTIC
1 ?IREI.INE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS.
PWS LD. #
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
� Reduc�ccd Pressure Princin_ le � Pressure Vacut� Breaker
o Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Sepal Number
Size
Located At
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Cer�tificd Tester
CerL Testa No.
Date
White - Customer's Copy Yellow -City Copy PinK - `T'ester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF aI.'FR
Double Check Valve Assembly
1st Chec1:
2nd ChecI:
Reiief Valve
:fir Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight a
Opened at
Opened at
nsid
Tit D
Leaked �
psid
nsid
RP- nsid
Leaked a
Did not Open o
Leaked a
Repairs
and
Materials
Used
Test Aftrr
DC- Closed
Closed Tight o
Opened at
Opmcd at
nsid
Repair
Tight 0
nsid
vsid
RP sid
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Cer�tificd Tester
CerL Testa No.
Date
White - Customer's Copy Yellow -City Copy PinK - `T'ester's Copy