2011_0422 (8)CIIECK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE 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 be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle o Pressure Vacutzm Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
Model lvimmber
Serial Number
Site
Located AL
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester - r ;-
Cent Testa No_ � Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACITLTM BRFaKF'R
Double Check Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Tcst
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Tight D
Leaked a
psid
vsid
RP- osid
Leaked o
Did not Opm [7
Leaked o
Repaus
and
Materials
Used
Test Af%er
DC- Closed
Closed Tight �
Opmcd at
Opined at
vsid
Repair
Tight 0
vsid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester - r ;-
Cent Testa No_ � Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy