2011_0505 (3)CHECK ONE.
IRRIGATION DOMESTIC
FIRELIN
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
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
� Reduced Pressure Principle � Pressure Vacuum Breaker
Q Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
.. _.
Cent. Tester No. Date
Wt�iite — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1�iBLY
PRESSURE VACUUM BRF�>`'T'R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Iainal Test
DC- Closed
Closed Tight D
Opened at
Opened at
nsid
Tight D
Leaked �
psid
nsid
RP- nsid
Leaked C
Did not Open o
Leaked o
Rcp airs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opened a[
nsid
Repair
Tight a
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
.. _.
Cent. Tester No. Date
Wt�iite — Customer's Copy Yellow —City Copy Pink — Tester's Copy