2011_0531 (5)CIIEC,K ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFT.OW 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 TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle � Pressure Vaccn***+ Breaker
fl Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size �.'
Model Number
Serial Number
Located At
_..-
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tester
Cent Tester No_ Date
White — Customers Copy YeIIow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI.TLJM
BRF'A�R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight ,El
�
Opened at
Opened at
osid
Tight : ,t=1
Leaked D
psid
osid
RP- � osid
Leaked �
Did not Open o
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP std
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
Certified Tester
Cent Tester No_ Date
White — Customers Copy YeIIow —City Copy Pink — Tester's Copy