2011_0422 (13)CIIECI� ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEA�LY TEST AND MA.Li�iI'ENANC'E 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
�- Reduced Pressure Principle D Pressure Vag-**+***+ Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is certified to be true.
Firm Name _
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Testa No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM SRRas.'FR
Double Check Valve Assembly
1st Cher:
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
InitiaI�Test
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Tilt a
Leaked o
psid
nsid
RP- o�id
Lcalced �
Did not Opm D
Leaked D
Repairs
and
MataiaLs
Used
Test Afizr
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Repair
Tight O
nsid
nsid
RP sid
The above is certified to be true.
Firm Name _
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Testa No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy