2012_1011CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE 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 certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Model Number L J Located At
Serial Number
The above is certified to be true.
Firm Name Certified Tester
Firm Address �'n' ! ` t1 . �'" s1 Cert. Tester No: OCY Date
Gauge #
Date last accuracy tested C '
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight 13
RP- I i� sid
Leaked ❑
� � �
psid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight 13
nsid
nsid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address �'n' ! ` t1 . �'" s1 Cert. Tester No: OCY Date
Gauge #
Date last accuracy tested C '
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy