2011_0505CIIE�K UNEc
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS_
PWS LD. # _
LOCATION OF SERVICE:
The backt7ow 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 ASSEh�ffiLY
� Reduc. -d Pressure Pr1IIC1Dle a Pressure Vacuum Breaker
O Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent Testa No.
Dace
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM
BRFaI.'FR
Double Check Valve Assembly
1st Checl:
2nd C'hecic
Relief Valve
Air Inlet
Check Valve
htitial Test
DC- Closed
Closed Tilt �
Opened at
Opened at
osid
Ti�at �
Leaked �
psid
osid
RP- osid
Leaked o
Did not Open o
Leaked o
Rcp airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Oprned at
Opined at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent Testa No.
Dace
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy