2011_0422 (9)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKF'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D_ #
LOCATION OF SERVICE: a
The backt7ow prevention assembly detailed below bas been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
D Reduc. -d Pressure Principle � Pressure Vacuimm Breaker
� " Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer - Size
Model I�iumber Located AL
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
bate Iast accuracy tested
Certified Tester t �. , -. -_ ;�{ �' �-=v --
Cent Tester No_ � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFas."F'R
Double Check Valve Assembly
1st Checl:
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Tighe C3
Leaked �
psid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked �
�Paz�
and
Materials
Used
Tcsi After
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Repair
Tight D
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
bate Iast accuracy tested
Certified Tester t �. , -. -_ ;�{ �' �-=v --
Cent Tester No_ � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy