2011_0531 (2)CIiECK ONE:
IRRIGATION DO 11°i ESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: --
PWS I_D. #
LOCATION OF SERVICE:
The backllow 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 Va�-u� Breaker
fr7 Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true. " �
Firm Name � �f� r.. � �-' �-'� � '� rLO � Certified Tester �� d i T ,� 14 S Dri/J
Firm Address J G� 8 � �P� �l - ��7SQ5 � Cert Testa No. Date � -3 � — ��
,,// T—
Gauge # 3�Z T�
Date Iast accuracy tested
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFLFA�'R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight q
Opined at
Opined at
osid
Tilt t3
Leaked ��
psid
osid
RP- osid
Leaked D
Did not Open a
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true. " �
Firm Name � �f� r.. � �-' �-'� � '� rLO � Certified Tester �� d i T ,� 14 S Dri/J
Firm Address J G� 8 � �P� �l - ��7SQ5 � Cert Testa No. Date � -3 � — ��
,,// T—
Gauge # 3�Z T�
Date Iast accuracy tested
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy