2011_0620 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELIN
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. # _
LOCATION OF SERVICE:
The backl'low prevention assembly detailed below has been tested and maintained as required by �hCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle D Pressure Va�-u� Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Nimmber
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Cent_ Tester No.
Dau
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V ACLILTM
BRA+ —F'R
Double Check Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight D
Leaked �
psid
osid
RP- osid
Lcai:ed o
Did not Open o
Leaked o
Rep airs
and
Materials
used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight a
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Cent_ Tester No.
Dau
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy