2011_0422 (21)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE �--- "
BACZ{FI.OW PREVENTION ASSEA�LY 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
� Reduced Pressure Principle o Pressure Vacuimm Breaker
d -' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true_
Firm Name
Firm Address _ -_
Gauge #
Date last accuracy tested
Certified Tester ,° � =`-
Cat Testa No. Date
White - Customer *s Copy YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFai.'FR
Double Cheek Valve Assembly
1st Chet1:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
x.
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
vsid
Tilt o'
Leaked D
psid
vsid
RP- Dsid
Leaked o
Did not Open o
Leaked o
Rep airs
and
Materials
Us«i
Test ARcr
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Repair
Tight [7
vsid
vsid
RP sid
The above is certified to be true_
Firm Name
Firm Address _ -_
Gauge #
Date last accuracy tested
Certified Tester ,° � =`-
Cat Testa No. Date
White - Customer *s Copy YeIIow -City Copy Pink - Tester's Copy