2011_0824CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFT.OW PREVEN'T'ION ASSEMBLY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE:
The backt'low 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 Vacuum Breaker
o Double Check Valve � Atmosphere Vacuum Breaker
Manufacnser
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 -
Cut Tests No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRFAT�'FR
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Ti°}rt �
Leaked o
psid
osid
RP- osid
Leaked �
Did not Open D
Leaked �
Rep airs
and
Materials
Used
Test Afire
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true_
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Tester -
Cut Tests No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy