2011_0422 (4)CIIECii 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
o Reduced Pressure Principle � Pressure Vacuinn Breaker
O Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer - � Size
Modei Number Located At -
Serial Number
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No. Date
White — Customers Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL.TL.TM BRFaKFR
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
osid
Tight �
Leaked o
psid
osid
RP- osid
_
Leaked 0
Did not Open o
Leaked D
�Paz�
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined 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
Cent Tester No. Date
White — Customers Copy Yellow —City Copy Pink — Tester's Copy