2011_0413CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backllow prevention assembly detailed below has been tested and maintained as required by TC'FQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
D Reduced Pressure Principle a Pressure Vacuum Breaker
o Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Testa
Cent Tester No_
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaKFR
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Tilt o
Leaked �
psid
nsid
RP- '� nsid
Leaked o
Did noc Open o
Leaked o
�P�';' -`
and
Materials
Used
Test Agar
DC- Closed
Closed Tight D
Opened at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Testa
Cent Tester No_
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy