2011_0531 (11)CIIECK ONE.
IRRIGATION llOMESTIC
FIRELYNE
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 certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
-._ Reduced Pressure Principle a Pressure Vacutmz Breaker
o Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size
Modei Number
Seriai Number
Located At
The above is certified to be trite.
j � r«L
Firm Name • `'' `� � " � ° �� S.s I !t"�� 1 Certified Tester
Firm Address S«O//B A VP ry, !L' � 7So�,6 Cert. Testa No.
Gauge # _�7Z Tln
Date last accuracy tested 3 `3 —� �
Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRE_AT�'R
Double Check Valve Assembly
1st Chek3:
tad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ; �l
Openecj at
Opened at
vsid
Tight C7..
Leaked o
psid
osid
RP- vsid
Leaked a
Did not Open o
Leaked �
Rtpairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight 0
osid
vsid
RP sid
The above is certified to be trite.
j � r«L
Firm Name • `'' `� � " � ° �� S.s I !t"�� 1 Certified Tester
Firm Address S«O//B A VP ry, !L' � 7So�,6 Cert. Testa No.
Gauge # _�7Z Tln
Date last accuracy tested 3 `3 —� �
Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy