2011_0422 (28)CHECK ONE.
IRRIGATION
DOMESTIC
FIRELYNE ""
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D_ #
LOCATION OF SERVICE: � - ;?�= jri , F- � i .
r
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' Reduced Pressure Principle ❑ Pressure Vacut� Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address _- - - __
Gauge #
Date Last accuracy tested
Certified Tester � =..
CerL Tester No. Date
White - Customer's Copy Yellow -City Copy Piink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT�R
Double Cheek Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
_Closed Tight ❑
Opened at
Opeaed at
vsid
Ti°tit e7
Leaked ❑
psid
vsid
RP- vsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address _- - - __
Gauge #
Date Last accuracy tested
Certified Tester � =..
CerL Tester No. Date
White - Customer's Copy Yellow -City Copy Piink - Tester's Copy