2011_0422 (22)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D_ #
LOCATION OF SERVICE: -> %!'t- ��:iRvt I %i% � 6'� -/7` /,l. c� ���L -/! , %.�
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 Reduced Pressure Principle o Pressurc Va�v� Breaker
O -''� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Ntmzber --{> :. Located At
Serial Number
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Tester , . , , . . --_
Cent Testa No. Date �,
YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'FR
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight Cr
Opened at
Opened at
osid
Tight Q"
Leaked D
psid
osid
RP- osid
Leaked �
Did not Open �
Leaked �
Repaus
and
Materials
Used
Test ARer
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight �
Dsid
osid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Tester , . , , . . --_
Cent Testa No. Date �,
YeIIow -City Copy Pink - Tester's Copy