2011_0422 (24)CIIECI� ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND M�►INTENANCE 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
D Reduc�i Pressure Principle D Pressure Vacutmm Breaker
� Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is certified to be true.
Firm Name -
Firm Address
Gauge #
Date last accuracy tested
White — Customers Copy
Certified Testa :' - � <<
Cert. Tester No. _ Date
Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLII.TM BRE_A►�'R
Double Check Valve Assembly
1st Checl:
2nd Chec1:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D'
Opeaed at
Opened at
nsid
Ti�L C7"
Leaked �
psid
nsid
RP- nsid
Leaked �
Did not Open a
Leaked a
Rep airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight a
nsid
nsid
RP sid
The above is certified to be true.
Firm Name -
Firm Address
Gauge #
Date last accuracy tested
White — Customers Copy
Certified Testa :' - � <<
Cert. Tester No. _ Date
Yellow —City Copy Pink — Tester's Copy