2011_1019CHECK ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The 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
� Reduced Pressure Principle O Pressure Varuu**+ Breaker
-� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Serial Number
Located At
The above is certified to be trot_
Firm Name .5oibt2
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cezt_ Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Tight �
Leaked �
psid
nsid
RP- bsid
Leaked o
_
Did not Open o
Leaked �
Rcpaus
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be trot_
Firm Name .5oibt2
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cezt_ Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester`s Copy