2011_0422 (18)CfIECK ONE=
IRRIGATION DOMESTIC FIR ELIN E
BACKFT.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 TCFQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
D' Rtduc�i Pressure Principle o Pressure Vacuinn Breaker
D 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
Certified Tester
Cent. Tester No. � � '' Date -t -
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLTiJM BRF'A�'F'R
Double Check Valve Assembly
1st Cher:
Znd Check
Relief Valve
Air Inlet
Check Valve
Initial rest
DC- Closed �
Closed Tight o
Opm«3 at
Opined at
nsid
Tight G�
Leaked a
psid
nsid
RP- -` nsid
Leaked �
Did not Opm o
Leaked D
Rcp atrs
and
Materials
Used
Test Af%er
DC- Closed
Closed Tight o
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. Tester No. � � '' Date -t -
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy