2011_0505 (2)CIIECK ONE=
IRRIGATION
ll O M ESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MA.INI'ENANCE REPORT
NAIviE 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 Reduces Pressure Principle D Pressure Vacutms Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Ntmmber
Serial Number
Size
Located At
The above is certified to be true_
Fitm Namc
Firm Address
isauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No.
Date
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEriiBLY
I PRESSURE vACLTLIM
BRFAI�"F'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight D
RP- i �s psid
Leaked �
psid
osid
Leai:ed �
Did not Open O
Leaked o
Rcp airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tight Q
nsid
osid
RP sid
The above is certified to be true_
Fitm Namc
Firm Address
isauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No.
Date
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy