2011_0422 (20)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE '-''-
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE 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
� Reduc. -d Pressure Principle � Pressure Va�-tt� Breaker
o Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size --
Model Number Located AL
Serial Number
E.
The above is certified to be true.
Firm Name
Firm Addt�ss
Gauge #
Date last accuracy tested
Certified Tester � � '' :tc�_..-
Cert. Tester No. Date '
White - Customer`s Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJT.TM BRFAT.'F'R
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight 0'
Opened at
Opened at
osid
Tilt C3'
Leaked C7
psid
osid
RP- osid
Lcai:ed �
�
Did not Oprn o
Leaked C7
Rtpai�s
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opwed at
osid
Repair
Tigktt D
osid
osid
RP std
The above is certified to be true.
Firm Name
Firm Addt�ss
Gauge #
Date last accuracy tested
Certified Tester � � '' :tc�_..-
Cert. Tester No. Date '
White - Customer`s Copy Yellow -City Copy Pink - Tester`s Copy