2011_0531 (12)CIIECK ONE =
4
IRRIGATION
DOMESTIC -
FIRELINE
BACTCFI.OW PREVEN'T'ION 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
Reduces Pressure Principle o Pressure Vac-trL•*n Breaker
� Double Check Valve o Atrnospherc Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
r .�
Firm Name • =� tr � � ras �a YK ��� /�"`� � _ -...�, �_' Certified Tester Z S� `f' _
Firm Addrzss -� b � S � V� tJ r G Cent Tester No. �S Z� Date
T75So56
Gauge # 3 - 7`7�tn /
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRFaKFR
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ,LI
Opined at
Opened at
nsid
Tight -�1,
Leaked D
_ � �` psid
nsid
RP- nsid
Lccied �
Did not Opm o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight a
Opm«i at
Opined at
nsid
Repair
Tight 0
nsid
nsid
RP sid
The above is certified to be true.
r .�
Firm Name • =� tr � � ras �a YK ��� /�"`� � _ -...�, �_' Certified Tester Z S� `f' _
Firm Addrzss -� b � S � V� tJ r G Cent Tester No. �S Z� Date
T75So56
Gauge # 3 - 7`7�tn /
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy