2011_0505 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELIN
BACKFI.OW PREVENTION ASSEMBLY TEST AND MA.IiV'I'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backf7ow 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 Reduced Pressure Principle a Pressure Vacua Breaker
O Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be trot_
Firm Name
Firm Addrsss - -_ -- -- --
Gauge #
Date Iast accuracy tested
Certified Tester
CerL Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'FR
Double Check Va�xe Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opened at
nsid
Ti�bt fl
Leaked D
psid
vsid
RP- vsid
Leaked �
Did not Opm �
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight �
Dsid
vsid
RP std
The above is certified to be trot_
Firm Name
Firm Addrsss - -_ -- -- --
Gauge #
Date Iast accuracy tested
Certified Tester
CerL Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy