2011_0422 (16)CIIECK ONE:
IRRIGATION
llOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: � r
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 a Pressure Va�-+n***+ Breaker
Double Check Valve a Atmosphere Vacuum Breaker
Manufacttaer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate Iast accuracy tested
Certified Tester ; ,'__ c.
Cert_ Testa No. _. Date `'
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BFZFAiZFR
Double Check Valve Assembly
Ist Check
?nd Checi:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
_Closed Tight �
Opined at
Opined at
vsid
Tilt �3'
Leaked o
psid
vsid
RP- psid
Leai:ed D
Did not Opm a
Leaked o
Rep airs
and
Materials
Used
Test Af%er
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight o
psid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate Iast accuracy tested
Certified Tester ; ,'__ c.
Cert_ Testa No. _. Date `'
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy