2011_0308CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEA�LY 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
Q' Reduc�i Pressure Principle o Pressure Vacutnn Breaker
o Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size
Modei Number
Serial Number
Located At
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
llate last accuracy tested
Certified Tester - , �,
,;,,
Ca[. Testa No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaKFR
Double Check Valve Assembly
1st Cher:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[ �
Opened at
Opened at
osid
Tight �
Leaked o
psid
osid
RP- osid
Leaked t7
Did not Oprn O
Leaked a
�P ��
and
Materials
used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP std
The above is certified to be true.
Firm Namc
Firm Address
Gauge #
llate last accuracy tested
Certified Tester - , �,
,;,,
Ca[. Testa No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy