2011_0310CIIECK ONE_
IRRIGATION DOMESTIC FIRELINE
BACKFI.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 a Fressurc Vacuum Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Iv Lmaber
Serial N�ber
Size
Located AL
The above is certified to be true.
Fitm Name
Firm Address
Gauge #
Date IARt accuracy tested
Certified Tester
Cert. Tester No.
Dau
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR��R
Double Cheek Valve Assembly
1st Chec1:
2nd Chek:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight []
Opined at
Opined at
nsid
Tight Cd
Leaked o
gsid
nsid
RP- nsid
Lcal:ed �
Did not Opm O
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight v
Opined at
Opined at
nsid
Repair
Tight 0
nsid
nsid
RP sid
The above is certified to be true.
Fitm Name
Firm Address
Gauge #
Date IARt accuracy tested
Certified Tester
Cert. Tester No.
Dau
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy