2011_0505 (3)CIIECI{ ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D- #
LOCATION OF SERVICE:
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is ccrtited to be operating within acceptable parnncters-
TYPE OF ASSEMBLY
o Reduced Pressure Principle � Pressure Vacuimm Breaker
o Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located AL
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Celt Testa No. - Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFai.'FR
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Tcst
DC- Closed
Closed Tight la'
Opined at
Opined at
osid
Tight ®'
Leaked �
psid
osid
RP- .� -`_ flsid
_ �_
Leaked �
Did not Open �
Leaked a
Rap airs
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Celt Testa No. - Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy