2011_0426 (7)CIIECK ONE.
IRRIGATION DOMESTIC FIRELIN E
BACT�'LOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE 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
� Reduced Pressure Principle C Pressure Vacuum Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
17ate last accuracy tested
� ��.. _. :ti _..
Cat Tests No_
Date
White - Customer`s Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEi�iBLY
PRESSL -RE VACLTUM BRF'41�'FR
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opened at
Opened at
nsid
Tilt O
Leaked O
psid
nsid
RP- nsid
Leaked c
Did not Open o
Leaked o
Rcp airs
and
Mat$ials
Used
Test ARcr
DC- Closed
Closed Tight D
Opened at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
17ate last accuracy tested
� ��.. _. :ti _..
Cat Tests No_
Date
White - Customer`s Copy Yellow -City Copy Pink - Testers Copy