2012_0628CIIECK ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The bacl�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuttm Breaker
^ Double Check Valve � Atmosphere Vacuum Breaker
ManufacLiser
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name -Ol ACCURACY BACKFLOW Certified Tester
Firm Address RICIIARDSON, TX 75083 -0416 Cert. Tester No. Date
Gauge # � `�a Z o i -t 2
Date last accuracy tested
T� ! - r '
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 Checl:
2nd Cheki:
Relief Valve
Air Inlet
Check Valve
Initial Tat
DC- Closed
Closed Tight t7
Opened at
Opined at
osid
Tight �
Leaked �
psid
osid
RP- osid
Leaked o
Did not Open o
Leaked '�
Rap airs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name -Ol ACCURACY BACKFLOW Certified Tester
Firm Address RICIIARDSON, TX 75083 -0416 Cert. Tester No. Date
Gauge # � `�a Z o i -t 2
Date last accuracy tested
T� ! - r '
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy