2011_0531 (10)CHECK ONE:
IRRIGATION DOMESTIC FIR ELIN E
BACKFT.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 TCGQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
ice._ Reduced Pressure Principle a Pressure Vacua**+ Breaker
O Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Modei Number
Seriai Number
Located At �G>Ot � Ali <i %U�'eJ:'
The about is certified to be true.
Firm Name • ��, ` ` "� �:- `��"r Certified Tcsur
Firm Address S��"�' �"'ry , rC . 7-� [.tom �`- Cert Tests No.
Gauge # � %z %(cam
Date Iast accuracy tested � " �� /�
Dau
White — Customers Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFZFA�'R
Double Cher3c Valve Assembly
1st Chek:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �•.
Opcned.at
Opened at
nsid
Ti°ttt [3
Leaked O__'�_psid
nsid
RP- nsid
�
Leaked a
�
Did not Open o
Leaked O
Repaus
and
MataiaLs
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opezied at
nsid
Repair
Tight �
nsid
nsid
RP std
The about is certified to be true.
Firm Name • ��, ` ` "� �:- `��"r Certified Tcsur
Firm Address S��"�' �"'ry , rC . 7-� [.tom �`- Cert Tests No.
Gauge # � %z %(cam
Date Iast accuracy tested � " �� /�
Dau
White — Customers Copy Yellow —City Copy Pink — Tester's Copy