2011_0422 (26)CHECK ONE:
IRRIGATION
llOMESTIC
FIRELINE -
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
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 paran�ctcrs.
TYPE OF ASSEMBLY
CI" Reduced Pressure Principle o Pressure Var+n�**+ Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Modei Number Located At
Serial Number
The above is edified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tester � � : � � :. , := - --
Cert. Tester No. ` � Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJLTM BRE_AI�'R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
vsid
Tilt �
Leaked O
psid
vsid
RP- psid
Leaked o
Did not OpeII o
Leaked o
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight [7
Opened ai
Opened at
vsid
Repair
Tight [7
vsid
psid
RP sid
The above is edified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tester � � : � � :. , := - --
Cert. Tester No. ` � Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy