2011_0330CIIECK ONE:
IRR.IGA TIO N DOMESTIC
FIRELINE
BACKFZOW PREVENTION ASSEI��LY TEST AND MAI1�11'ENANCE 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'CGQ
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
o Reduced Pressure Principle � Pressure Vac-*n***+ Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACIJLTM BFZFa��R
Double Check Valve Assembly
1st Cher: 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight � Opined at Opined at nsid
Tight a Leaked o psid nsid
RP- nsid
Leaked � Did nat Opm a Leaked o
Rtpairs
and
Materials
Used
Test ARer DC- Closed Closed Tight o Opined at Opined at nsid
Repair Tight D nsid nsid
RP sid
The above is certified to be true.
Firm Namc Certified Tester
Firm Address Cent Tester No- Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy