2011_0422 (7)CIIECIi ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW 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
[� Reduced Pressure Principle � Pressure Vacuinn Breaker
� Double Check Valve O Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is calif. ed to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester -
Cat Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'aYCx'R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight � "
Opened at
Opened at
nsid
Tight a
Leaked o
psid
nsid
RP- nsid
Leaked D
Did not Open D
Leaked D
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is calif. ed to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester -
Cat Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy