2011_0422 (10)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE `
BACKF'LOW 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
CT Reduced Pressure Principle o Pressure Vann•*'+ Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At ,- _
Serial Number
The above is certified to be true.
Firm Name
Firm Addt�ess
Gauge #
Date last accuracy tested
White — Customer's Copy
Certified Tester t'r`y _.
Cent. Tester No. �� -� Date
Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLlLTM BRF.�i.�R
Double Check Valve Assembly
1st Checl:
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
initial Test
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Tight Q ""
Leaked �
psid
nsid
RP- nsid
Lcal.ed D
Did not Open o
Leaked D
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP std
The above is certified to be true.
Firm Name
Firm Addt�ess
Gauge #
Date last accuracy tested
White — Customer's Copy
Certified Tester t'r`y _.
Cent. Tester No. �� -� Date
Yellow —City Copy Pink — Tester's Copy