2011_0309CIIECi� ONE:
IRRIGATION llOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAI2�iTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: -- -
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certited to be operating within acceptable parameters.
TYPE OF ASSEMBLY
D Reduc°d Pressure Principle D Pressure Vacutnn Breaker
E+- "" Double Check Valve � Atmosphere Vacuum Breaker
Manufacttaer Size
Model Number
Serial Number
�,
a " "`-
r ,� '
Located AL '
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester <' , _ , (�' i' r'
Cent. Tester No_� Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEiVIBLY
PRESSURE VACUUM BR��R
Double Chec3c Valve Assembly
1st Checl:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �"
Opined at
Opened at
vsid
Ti�at Q"
Leaked 0
psid
vsid
RP- - psid
+
Leaked �
_ �
Did not Open O
Leaked o
�P��
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight o
vsid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester <' , _ , (�' i' r'
Cent. Tester No_� Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy