2011_0222CHECK ONE:
IRRIGATION
DOMESTIC
FIR E LIN E
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. _
PWS I_D- #
LOCATION OF SERVICE: < .. _J '.. � ._
The backtlow 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 Reduced Pressure Principle D Pressure Vacuum Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer - Size -
Model Number Located At
Serial Number
t.
The above is certified to be true. 1
Firm Name Certified Tester � �C V� � } �l �=-
Firm Address Cert. Tester No. �'5��� �� Date � ��— 1
Gauge #
Date Iast accuracy tested
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAC'LTCTM BRE_AT�'R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tilt �
Closed Tigh[ Y�
Leaked o
Opened at
psid
Opened at
osid
osid
RP- osid
Leaked o
Did not Opm o
Lealai a
Rep airs
and
Matezials
Used
Test ARrs
DC- Closed
Closed Tight C7
Opined at
Opined at
osid
Repair
Tight a
osid
osid
RP sid
The above is certified to be true. 1
Firm Name Certified Tester � �C V� � } �l �=-
Firm Address Cert. Tester No. �'5��� �� Date � ��— 1
Gauge #
Date Iast accuracy tested
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy