2011_0708ClIECK ONE_
IRRIGATION
ll0 M ESTIC
FIRELINE
BACKFT,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
�. /_�T.�T.��� +.idyl
PWS I.D. # _
LOCATION OF SERVICE:
The backllow prevention assembly detailed below has been tested and maintained as required by "I'CEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
D Rrduc. -,d Pressure Principle o Pressure Va�-u� Breaker
O Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Fitm Name _
Firm Address
Gauge #
bate last accuracy tested
Certified Tester
Cent Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A��R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opeaed at
vsid
Tight �
Leaked �
psid
vsid
RP- psid
Leaked �
Did not Opm o
Leaked o
Repaus
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight [7
psid
vsid
RP std
The above is certified to be true.
Fitm Name _
Firm Address
Gauge #
bate last accuracy tested
Certified Tester
Cent Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy