2011_0629 (2)CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFT.OW 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 "1'CEQ
regulations and is ccrti f ied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle � Pressure Vacuum Breaker
o Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located AL
The above is cettif•ed to be true_
Fitm 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 VACUUM BRE_A►�'R
Double Check Valve Assembly
1st Checl:
2nd Cbect:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opined at
Opined at
vsid
Ti�L 13
Leaked o
psid
vsid
RP- osid
Leaked o
Did not Opm o
Leaked o
�P��
and
Materials
Used
Test Afirr
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight o
osid
osid
RP sid
The above is cettif•ed to be true_
Fitm 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