2011_0207CffECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: - - '
The backYlow 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 Reduc. -d Pressure Principle o Pressure Vacuinn Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
_.: __ r
Certified Tester %" ', ,
Ccrt. Tester No. � Date �'
White - Customer`s Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaKFR
Double Check Valve Assembly
1st Chek3:
2nd Chet:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight - �'"
Opined at
Opined at
nsid
Ti°hi --�`
Leaked �
psid
nsid
RP- nsid
Leaked o
-.:;
�
Did not Opm o
Leaked o
Rep airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight O
Opmcd at
Opined at
nsid
Repair
Tight 0
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
_.: __ r
Certified Tester %" ', ,
Ccrt. Tester No. � Date �'
White - Customer`s Copy Yellow -City Copy Pink - Testers Copy