2011_0422CIIECIi ONE:
IRRIGATION DOMESTIC FIRELIN E
BACZCFI.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 ccrtilied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle � Pressure Vacutnn Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Serial Number
Located AL
The above is certified to be true.
Firm Name
Firm Addrzss
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No.
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJTJM BRF'AT�'R
Double Chec3c Valve Assembly
1st Checl:
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[ o
Opined at
Opened at
nsid
Tight o
Leaked �
psid
nsid
RP- nsid
Leaked o
Did not Opm C7
Leaked o
�P��
and
Materials
Used
Test ARer
DC- Closed
Closed Tight [7
Opined at
Opined at
nsid
Rtpair
Tight [7
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Addrzss
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No.
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy