2011_0412CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIrTI'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: � i
The backllow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
o _ Reduced Pressure Principle a Pressure Va�-tt� Breaker
o . Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be tzue.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
'_ Certified Tester
Cent Tester No. � Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR��R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tighe t?
Opined at
Opined at
nsid
Tight__ Q
Leaked �
psid
nsid
_
RP- -nsid
Leaked �
Did not Opm O
Leaked D
Rap airs
and
Materials
Used
Test ARrr
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be tzue.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
'_ Certified Tester
Cent Tester No. � Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy