2011_0311CIIECK ONE:
IRRIGATION
DOLYIESTIC -
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backtlow 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
Rcduc. -d Pressure Principle D Pressure Vaculnn Breaker
O Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer � Size ' ��'`
Model Number Located At
Serial Number n�ulc- in� �j � � `� � Ss5
-
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUL7M BRE_A�'F'R
Double Check Valve Assembly
1st Cheri:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o'
Opened at
Opined at
n51d
Tight � �
Leaked �
- -� psid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked �
�P��
and
Materials
Used
Test Agar
DC- Closed
Closed Tight o
Opmcd at
Opmcd at
nsid
Repair
Tigtlt [7
nsid
vsid
RP sid
The above is certified to be true_
Firm Name
Firm Addres_s
Gauge #
Date last accuracy tested
Certified Tester
CaL Testa No.
,,
7,
r � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy