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2011_0308 (5)CIIECK ONE: IRRIGATION DOMESTIC �. FIRELINE BACKFI.OW PREVENTION ASSEMBLY TEST AND MA.INTENANC� 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 he operating within acceptable parameters. TYPE OF ASSEMBLY b Reduc -d Pressure Principle o Pressure Va�-*�•**+ Brealccr � Double Check Valve o Atmosphere Vacuum Breaker Manufacturer Size Model Number Located At Serial Number The above is certified to be true. Firm Name Firm Address _ ____ Gauge # Date last accuracy tested Certified Testa Cent Tester No. ' 3�ate White — Customer's Copy Yellow —City Copy Pink — Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACITCiM BRFAKF'R Double Chec3c Valve Assembly 1st Checl: 2nd Check Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight '©' Opened at Opened at osid Ti�L 6i� Leaked � ! psid osid RP- osid Leaked o Did not Open o Leaked o Repairs and Materials Used Test Auer DC- Closed Closed Tight o Opened at Opened at nsid Repair Tight D osid osid RP sid The above is certified to be true. Firm Name Firm Address _ ____ Gauge # Date last accuracy tested Certified Testa Cent Tester No. ' 3�ate White — Customer's Copy Yellow —City Copy Pink — Tester's Copy