2010_1229CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE �"
BACKFI.OW PREVENTION ASSEA�LY TEST AND MAIl�i'I'ENANCE REPORT
NAME OF PWS_
PWS I.D. #
LOCATION OF SERVICE:
The backllow 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
� Reduced Pressure Principle � Pressure Vacuimi Breaker
o Double Check Valve � Attnospherc Vacuum Breaker
Manufactttrer Size -
Model Ntmiber :� =' � � Located At -
Serial Number
The above is certified to be true.
Firm Namc
Firm Address -
Gauge #
llate Last accuracy tested
Certified Tester
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUTJM BR��R
Double Check Valve Assembly
1st Checl:
2nd Checl:
RefieF Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Ti�L o
Lcal:cd o
psid
nsid
RP- nsid
Leaked D
Did not Open o
Leaked �
Rcpai�s
and
Materials
Used
Test ARu-
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight �
osid
nsid
RP sid
The above is certified to be true.
Firm Namc
Firm Address -
Gauge #
llate Last accuracy tested
Certified Tester
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy