2011_0422 (5)CiIECK ONE=
IRRIGATION ll0 M ESTIC FIR ELIN E
BACKFI.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 he operating within acceptable parameters.
TYPE OF ASSEMBLY
�] Reduced Pressure Princivle � Pressure Vacuinn Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
- � � Located At
The above is certified to be true.
Firm Name .
Fitm Address
Gauge #
llate last accuracy tested
Certified Tester - --
Cent Tester No. _ Date
White — Customer's Copy YeIIow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�R
Double Check Valve Assembly
1st Chec1:
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tigbt �
Opined at
Opined at
nsid
Tight a
Leaked �
psid
nsid
RP- nsid
Leaked a
Did not Opm O
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight [7
nsid
nsid
RP sid
The above is certified to be true.
Firm Name .
Fitm Address
Gauge #
llate last accuracy tested
Certified Tester - --
Cent Tester No. _ Date
White — Customer's Copy YeIIow —City Copy Pink — Tester's Copy