2011_0920CIIECK ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEA'18LY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backtlow 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
0 Reduced Pressure Principle � Pressure Vacucnn Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Modes Number
Serial Nimmber
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
. . -. �i
Cert. Tester No.
Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL.TLJM BRE_A�'F'R
Double Check Valve Assembly
1st Chec3c
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Tight o
Leaked a
psid
osid
RP- osid
Leaked �
Did not Opm D
Leaked o
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
. . -. �i
Cert. Tester No.
Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy