2011_0721CHECK +ONE:
IRRIGATION llO M ESTIC FIR ELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS_
PWS I.D. #
LOCATION OF SERVICE: � r � "`
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certitied to be operating within acceptable parameters_
TYPE OF ASSEMBLY
o Reduced Pressure Principle a Pressure Vacua Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate Iast accuracy tested
.. _.
. -._ -�-
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRi:'as.�R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight G7
Opened at
Opened at
vsid
Tilt Q"
Leaked o
psid
osid
RP- vsid
Leaked [7
Did not Open O
Leaked o
�Pa+re
and
Materials
Used
Test ARer
DC- Closed
Closed Tight D
Opened at
Opened at
osid
Repair
Tight Q
osid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate Iast accuracy tested
.. _.
. -._ -�-
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy