2011_0531CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE `'�
BACKFLOW PREVENTION ASSEMBLY TEST AND MA.INTENANC� 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
o Reduced Pressure Principle � Pressure Vacutmm Breaker
E7; Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer � Size �='
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name � ��i �r `' ,�"I -' - � �� � Certified Tests � `� � `
Firm Address 576'8/ /�'� �� 756 Cert. Tester No. _- - Date -- -
Gauge # 3 %4 T"
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJIJM BRE_A�R
Double Check Valve Assembly
1st Check
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D.
Opened at
Opened at
nsid
Tight ,F�a
Leaked o
psid
nsid
RP- -nsid
Lcal:ed o
Did not Open O
Leaked [7
Rcpatrs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Repair
Tight D
nsid
nsid
RP std
The above is certified to be true.
Firm Name � ��i �r `' ,�"I -' - � �� � Certified Tests � `� � `
Firm Address 576'8/ /�'� �� 756 Cert. Tester No. _- - Date -- -
Gauge # 3 %4 T"
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy