2012_0827CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACXFLOW 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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuirn Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At 1 N (1 4 w'� -
The above is certified to be true.
Firm Name
Firm Address 1 l �` �l t . , �r,, r �' ►-1 �' =���1 i
Gauge #
Date last accuracy tested
Certified Tester
Cat Testa No. '-) n t -1,1 r.
Date
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
osid
Tight ❑
Leaked ❑
psid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address 1 l �` �l t . , �r,, r �' ►-1 �' =���1 i
Gauge #
Date last accuracy tested
Certified Tester
Cat Testa No. '-) n t -1,1 r.
Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy