2011_0413 (3)CHECK ONE=
IRRIGATION_ _ DOMESTIC FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv1E OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TCi✓Q
regulations and is certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
D Reduced Pressure Principle � Pressure Vacuum Breaker
�' Double Check Valve o Atmosphere Vacuum Breaker
Manufacun-er Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No. Date
White — Customers Copy YeIIow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF ATCFR
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opined at
Opined at
vsid
Tight �'
Leaked �
psid
vsid
RP- Dsid
Leaked o
Did not Opm O
Leaked 0
Rep airs
and
MatcziaLs
Used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight �
nsid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cert. Tester No. Date
White — Customers Copy YeIIow —City Copy Pink — Tester's Copy