2011_0422 (27)CIIEC,K ONE.
IRRIGATION
DOMESTIC
FIRELINE •-
BACKFLOW 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 TCGQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Q Reduced Pressure Principle o Pressure Vacuum Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer '�� Size
Model Number
Serial Number
Located At
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No_ Dau
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR>F'al�'F'R
Double Check Valve Assembly
1st Chec3:
2nd Cheek
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opened at
vsid
Ti�L �
Leaked o
psid
vsid
RP- vsid
Leaked o
Did not Opm o
Leaked C7
Rcpai�s
and
Materials
Used
Test ARtr
DC- Closed
Closed Tight �
Opined at
Opined at
vsid
Repair
Tight [7
vsid
vsid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No_ Dau
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy