2011_0208 (2)CHECK ONE:
IRRIGATION
/'tom
DOMESTIC
FIRE]LINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # J
LOCATION OF SERVICE : L�
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.
C -Reduced Pressure Principle
z'� Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size -�
Located At `W", %1� t-
The above is certified to be true.°
Firm Name Y4- f)" Certified Tester C� �' ✓�' i
Firm Address C� Cert. Tester No. P.J Date
Gauge #
Date last accuracy tested ? —! t( ` 1 c)
i
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tld2t,.
RP- �,
Leaked ❑
Closed Tight
Leaked 13
-'Opened at
Sid
Opened at
o5'd
Did not Open ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
Psid
Opened at
nsid
nsid
RP sid
The above is certified to be true.°
Firm Name Y4- f)" Certified Tester C� �' ✓�' i
Firm Address C� Cert. Tester No. P.J Date
Gauge #
Date last accuracy tested ? —! t( ` 1 c)
i
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy