2011_0106CIIECI� ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
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PWS I.D. #
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 a Pressure Va�-[nnn Breaker
L7 Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Dau
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Cheri:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight O
Opined at
Opined at
nsid
Tilt a
Leaked �
nsid
vsid
RP- nsid
Leaked 0
Did not Opm D
Leaked o
Rrpairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Dau
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy