2013_0103CHECK 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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer �A1 '1 I " ^ Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name Q Certified Tester `I'D -
Firm Address ' r A \ ,_ . °� _L tY Cert. Tastes No. Dl t� 5b
Gauge #
Date last accuracy tested f
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1IIBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
:fir Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Tight ❑
Leaked ❑
psid
_ osid
��JvJ
RP-----psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
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 Q Certified Tester `I'D -
Firm Address ' r A \ ,_ . °� _L tY Cert. Tastes No. Dl t� 5b
Gauge #
Date last accuracy tested f
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy