2011_0422 (19)CHECK ONE_
IRRIGATION DOMESTIC FIRELINE
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 TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduces Pressure Principle o Pressure Vacutmm Breaker
Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer
Model Iii umber
Serial Number
Size
=-1
Located At
��-y 17-- � �`
A E /C'� 4 �3Sr . �"'C� SIC >� i�
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
White — Customer's Copy
Certified Tester
Cert. Tester No. ,° - _ Date '
Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAC'LJUM BRFaKFR
Double Check Valve Assembly
1st Checl:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test �
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Ti�at C3-
,Leaked D
psid
vsid
RP- Dsid
Leaked o
Did not Open o
Leaked o
Rcpaus
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opined at
Opined at
vsid
Repair
Tight �
nsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
White — Customer's Copy
Certified Tester
Cert. Tester No. ,° - _ Date '
Yellow —City Copy Pink — Tester's Copy