2011_0422 (25)CIIECK ONE-
IRRIGATION ll0 M ESTIC FIR E LYN E
BACKFI.OW PREVENTION ASSEMBLY 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 TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Et Reduced Pressure Principle a Pressure Vacutmm Breaker
D Double Check Valve � Atmosphere Vacuum Breaker
:r
Manufacturer Size
Model Ivtrmber
Serial Number
Located AL `'_ �� -'�. _ -
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No. �_ Date �� 'r
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiT[JM BRFAT.'FR
Double Cbeck Valve Assembly
1st Chec1:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Tight �
Lcal:cd �
psid
osid
RP- vsid
Leaked o
Did not Open �
Leaked 0
Repairs
and
Materials
Used
Test Ai%er
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight o
vsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No. �_ Date �� 'r
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy