2011_1020CIIECK ONE=
IRRIGATION DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
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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
o Reduced Pressure Principle a Pressure Va�-u� 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 Addrtss
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Testa
Cent_ Tester No_ Date
Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJLTM
BF2.FA><.'FR
Double Check Valve Assembly
1st Chec3:
2nd Checl:
Refief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight er
Opcaed at
Opened at
nsid
Tighi o- '
Leaked �
psid
nsid
1
RP- nsid
Leaked �
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test ARrs
DC- Closed
Closed Tight D
Opened at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Addrtss
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Testa
Cent_ Tester No_ Date
Yellow -City Copy Pink - Testers Copy