2011_0422 (3)CIIECK ONE:
IRRIGATION llO M ESTIC FI RELIN
BACxFI.OW PREVENTION ASSEMBLY TEST AND MAI2�1'I'ENANCE 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
D Reduced Pressure Principle � Pressure Vacuum Breaker
O Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1�iBLY
PRESSURE VACUUM
BR��R
Double Check Valve Assembly
1st Checl:
2nd Chet]:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Tight Q
Leaked o
psid
nsid
RP- nsid
Leaked D
Did not Oprn O
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy