2011_0831CIIECI� ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY 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
� Reduced Pressure Principle � Presstirc Vacuum Breaker
p Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Serial Nimmber
Size
Located AL
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR��R
Double Check Valve Assembly
1st Checl:
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Ti�it D
Leaked o
psid
osid
RP- Dsid
Leaked o
Did not Open o
Leaked �
�Pazrs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opened at
Opened at
osid
Repair
Tight o
Dsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy