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2011_0810CHECK ONE: IRRIGATION DOMESTIC FIRELIN BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS LD. # LOCATION OF SERVICE: The backllow 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 Reduc°d Pressure Principle o Pressure Va�-utnn*+ Breaker � Double Check Valve o Atmosphere Vacuum Breaker Manufacturer Model Number Serial Number Size Located At The above is certified to be true. Fitm Name Firm Address _' __ Gauge # Date Iast 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 BFZF'AT.'FR Double Check Valve Assembly 1st Chekl: Znd Chekl: Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight ©•' Opined at Opined at osid Tilt Q. - "Leaked � psid osid RP- osid Lcal:ed D Did not Open o Leaked � Repairs and Materials Used Test ARer DC- Closed Closed Tight a Opined at Opined at _ osid Repair Tight o osid osid RP sid The above is certified to be true. Fitm Name Firm Address _' __ Gauge # Date Iast accuracy tested Certified Tester Cent. Tester No. Date White — Customer's Copy Yellow —City Copy PinK — Tester's Copy