2011_0330 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY 'TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The back(low 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
o Reducad Pressure Principle o Pressure Va�n�**+ Breaker
/� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Nana .: �,
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No- ` , Date -
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BREAKER
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[ Q:
Opined at
Opined at
nsid
Ti°hL D
Leakcri Ud_
psid
nsid
RP- nsid
Leaked o
���/ /
Did not Opm �
Leaked o
Repairs
and
j� �
/C- CL•Y�-v--�
�
MatuiaLs
used
�a .5
s "/, �,-, � 6 �� .� .
Test After
DC- Closed
Closed Tight p-
Opined at
Opined at
nsid
Repair
Tight 1yZ
nsid
nsid
RP sid
-
The above is certified to be true.
Firm Nana .: �,
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No- ` , Date -
White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy