2013_0607CHECK 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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 0 - Ij �- Size
Model Number t_
Serial Number
Located At n,
The above is certified to be true.
Firm Name �I - U� Certified Tester
Firm Address �� ' / � Cert. Testa No. -�7 s �` Date
J C1.�t!o
Gauge # 7 ) t-,
]date last accuracy tested
`7 ? ,a -7
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 ❑
RP -,pSid
Leaked ❑
Leaked ❑
psid
osid
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 �I - U� Certified Tester
Firm Address �� ' / � Cert. Testa No. -�7 s �` Date
J C1.�t!o
Gauge # 7 ) t-,
]date last accuracy tested
`7 ? ,a -7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy