2011_0628CiIECK ONE=
IRRIGATION DOMESTIC FIRE LIN
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't'CE��
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduc. -d Pressure Principle ❑ Pressure Vacuum Breaker
t� Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufact�ser
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name '
Fitm Address
Gauge #
Date last accuracy tested
Certified Tester
Cer[. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJLTM BRE_A�'F'R
Double Check Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opined at
Opined at
nsid
Ti°hc ❑
Leaked ❑
psid
nsid
RP- nsid
LeaI:ed �
Did not Opm ❑
Leaked ❑
Rep airs
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight ❑
Opined at
Opined at
nsid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name '
Fitm Address
Gauge #
Date last accuracy tested
Certified Tester
Cer[. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy