2011_0620CHECK ONE.
IRRIGATION
ll0 M ESTIC
FIRELIN
BACKF'I,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I -D. #
LOCATION OF SERVICE:
The backtlow prevention assembly detailed below bas 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 D Pressure Va�u� Breaker
O Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is certifiod to be true-
Firm Name
- �
Firm Address
Gauge #
llate Iast accuracy tested
Certified Tester
Cert- Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRFAKF'R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
:Closed Tight o
Opined at
Opined at
nsid
Tight �
Leaked o
psid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked �
Rep airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certifiod to be true-
Firm Name
- �
Firm Address
Gauge #
llate Iast accuracy tested
Certified Tester
Cert- Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy