2011_0422 (6)CIIECK ONE=
IRRIGATION DOMESTIC FIRELINE
BACTCFI.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
D Reduced Pressure Principle O Pressure Va�-u� Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true_
Firm Name � > _� f
Firm Address � � _ �� _- �__
Gauge #
Date last accuracy tested
Cettified Tester -
Cent Testa No. _ Date
White - Customer's Copy Ye11ow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJIJM BRE_A�R
Double Check Valve Assembly
1st Checl:
2nd Chekl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Tight a
Leaked D
psid
osid
RP- osid
Leaked �
Did not Open O
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opcaed at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true_
Firm Name � > _� f
Firm Address � � _ �� _- �__
Gauge #
Date last accuracy tested
Cettified Tester -
Cent Testa No. _ Date
White - Customer's Copy Ye11ow -City Copy Pink - Tester's Copy