2011_0422 (12)CIIECK ONE=
IRRIGATION
DOMESTIC
FIRELINE
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 certitied to be operating within acceptable paran�etcrs.
TYPE OF ASSEMBLY
o Reduced Pressure Principle o Pressure Vacuinn Breaker
o- Double Check Valve � Atmosphere Vacuum Breaker
Manufacnu er Size
Model Number Located At
Serial Number
The above is cc:tified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Testa .
Cent Tester No. Date
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 Chek1:
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Tilt Q
Leaked o
psid
osid
RP- DSld
Leaked o
Did not Opm O
Leaked a
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opined at
Opined at
osid
Repair
Tight a
osid
osid
RP sid
The above is cc:tified to be true.
Firm Namc
Firm Address
Gauge #
Date last accuracy tested
Certified Testa .
Cent Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy