2011_0330 (3)CHECK 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 N 04+7 Size
Model Number
Located At
Serial Number`
The above is certified to be true.
Firm Name ,... i � Certified Tester -
Firm Address % %r� Cert. Tester NoAolo m 3p Date
Gauge #
Date last accuracy tested
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
�1�
Tight ❑
RP
Leaked ❑
, " psid
it`
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
oSid
RP s
The above is certified to be true.
Firm Name ,... i � Certified Tester -
Firm Address % %r� Cert. Tester NoAolo m 3p Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy