2011_0614CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVEN'T'ION 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 "I'CEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
a Reduc:d Pressure Principle o Pressure Va�-uL•*%± Breaker
o Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size �"
Model Number Located At
Serial Number
The above is certi.ficd to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester �' "�
Cent. Tester No_'� Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACi.TUM BRFa7.'FR
Double Check Valve Assembly
1st Chekl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ' O
LSpcned at
Opened at
nsid
Tight D
Leaked o
psid
nsid
RP- DSld
Leaked o
Did not Open o
Leaked a
Repaus
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight O
nsid
nsid
RP sid
The above is certi.ficd to be true_
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester �' "�
Cent. Tester No_'� Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy