2011_0422 (2)CIIECK ONE.
IRRIGATION DOMESTIC FIRELIN E
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
T'he backtlow 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
o Reduces Pressure Principle o Pressure Vacuum Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located AL
Serial Ntmmber
The above is certified to be true.
Firm Name
Firm Addtrss
Gauge #
Date last accuracy tested
Certified Testa
Ccrt. Tester No_ Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opened at
Opened at
vsid
Tight o
Leaked �
vsid
vsid
RP- vsid
Leaked C7
Did not Opea o
Leaked o
Repairs
and
Materials
Used
Test ARa
DC- Closed
Closed Tight o
Opened at
Opined at
vsid
Repair
Tight o
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Addtrss
Gauge #
Date last accuracy tested
Certified Testa
Ccrt. Tester No_ Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy