2011_0422 (17)CIIECiK ONE:
IRRIGATION DOMESTIC FIR ELIN E
BACKF'I.OW 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 Varcr� Breaker
o 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 Address _ _
Gauge #
Date Iast accuracy tested
White - Customer's Copy
Certified Teste f, -� - -.
Cent Tester No. �. Date -
Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_a�'F'R
Double Check Valve Assembly
1st Check
tad Checl:
Reiief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
vsid
Tight o
Leaked o
psid
vsid
RP- vsid
Leaked �
Did not Opm D
Leaked �
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
vsid
Repair
Tight �
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address _ _
Gauge #
Date Iast accuracy tested
White - Customer's Copy
Certified Teste f, -� - -.
Cent Tester No. �. Date -
Yellow -City Copy Pink - Tester's Copy