2011_0513 (2)CHECK ONE.
IRRIGATION DOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD_ #
LOCATION OF SERVICE: . ' -�'
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certited to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Q Rcduc�i Pressure Principle � Pressure Vacutma Breaker
[� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Cemfied Tester
Cert. Tester No. _ - Dare
- �' r
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSE1�iBLY
PRESSURE VACUUM BRFA►i`'F'R
Double Check Valve Assembly
1st Chekl:
2nd Checi:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D"
Opined at
Opined at
psid
Tight D
Leaked �
psid
osid
RP -' osid
Leaked �
Did not Opm D
Leaked o
Repatrs
and
Materials
Used
Test ARcr
DC- Closed
Closed Tight �
Opined at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Cemfied Tester
Cert. Tester No. _ - Dare
- �' r
White - Customer's Copy Yellow -City Copy Pink - Testers Copy