2012_1119CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge # ` )W OC(
Date last accuracy tested '&-1 ! '
Certified Tester 71
Cent. Tester No. - � Date l 'O' I/ Z.
II I
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
L
C]
Tight
Leaked ❑
psid
osid
�a
RP- psid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
�� sid
Repair
Tight
psid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # ` )W OC(
Date last accuracy tested '&-1 ! '
Certified Tester 71
Cent. Tester No. - � Date l 'O' I/ Z.
II I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy