2012_0827 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: f"
PWS I.D. # 0 /, r
LOCATION OF SERVICE:
t- QRIV,
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 Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At P 141,V n O L
Serial Number
The above is certified to be true.
Firm Name
Firm Address Yr V! V 0 (iii _ 0 ( q' y
Gauge #
Date last accuracy tested
Certified Tester
Cei t. Tester No. P 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
psid
Tight ❑
Leaked ❑
psid
psid
RP- _psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Address Yr V! V 0 (iii _ 0 ( q' y
Gauge #
Date last accuracy tested
Certified Tester
Cei t. Tester No. P Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy