2011_0422 (11)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACTCFZOW 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 Varu� Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size - --
Model Number Located At
Serial Number
The above is certified to be true.
Fitm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester �^ <y.�. .
Cent Tester No. _ _ Date r
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_a�R
Double Check Valve Assembly
1st Chek:
Znd Cheri:
Relief Valve
Air Inlet
Check Valve
' 'Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Tight a
Leaked o
psid
nsid
RP- nsid
Leaked D
Did not Opm D
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Rtpair
Tight a
nsid
nsid
RP sid
The above is certified to be true.
Fitm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester �^ <y.�. .
Cent Tester No. _ _ Date r
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy