2011_0505 (4)CiIECI� ONE.
IRRIGATION
DOMESTIC
FIRELYNE
BACKFLOW 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 TCFQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle n Pressure Vacutnn Breaker
L3 _ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
,.
Model Number Located At �`
Serial Ivumbcr
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
. - =1 -
Cent Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BREAKER
Double Check Valve Assembly
1st Checl:
2nd Cheri:
RelieF Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 1�!'
Opined at
Opined at
osid
Tim; �
RP -�psid
Leaked D
psid
osid
Leaked a
� �
Did not Opm o
Leaked n
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight [7
Opined at
Opined at
osid
Repair
Tight a
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
. - =1 -
Cent Testa No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy