Freeport NIP(8.0)-LR050426· CtlBCK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PW$ 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
Manufactnr~r
Mod~l Number
S~iaI Number
l~:luced Pre~sur~ Pr/nc/pie
Double Check V~Ive
2 7'
m lh~m~ Vacuum Bnml~
m Atmosph~'~ V~uum Br~ak*r
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULrM BREAKIiR
Double Check Valve Ass-mhly
/~4~' 12ndCheck/-~ Relief Valve Airlnlet CheckVslve
1st Check
Iui~al T,st DC-Closed Clos~l Tight ~ ~ at Op~ned at ~sid
Tight ~ /Leak~l m psid psid
tl~'..<~' PP- psid
~ 0 Did not Op~ m l.~ak~xt m
Materials
Used
T~t ~ DC-Closed Closed Ti~t o Opened at Opted at psid
R~air Tight o psid psid
RP psid
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester~ Copy
CHECK ONE:
IRRIGATION '~'~'
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEM]~LY TF. ST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
OC^T O srmc :
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
Double Check Valve
Manufacturer
m Pr~ma~ Vacuum Bmak~
u Am~osphcre Vacuum Bre~ak~r
Siz~ ~ /~
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAIO~R
Double Check Valve Aar~mbly
lstCheck~tl/ 2ndCheck/~:) RellefYalve AirInlet CheckVaDe
Tight ~' a psid psid
~1 .SD' RP- psid
Lcakcd c~ Did not Open m Le~k~ m
Materials
Used
Te~t ~ DC-Closed Closed Tight m Opem~d at Ol~xi at psid
R~air Tight m ~_~psid paid
RP paid
The above is certified to b~ lruc.
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy