2011_0426 (4)CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVEN'T'ION ASSEA�LY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by "I'CEQ
regulations and is certifiied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduces Pressure Principle � Pressure Var11L/*n Breaker
O. Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
_.
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
.._. �-
Cent. Tester No.
Dare
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR��R
Double Check Valve Assembly
1st C1�eck
2nd Checl:
Relief Vaive
Air inlet
Check Valve
Initial Test
DC- Closed
Closed Tigh[ Q;-
Opened at
Opened at
nsid
Tilt �:,
Leaked �
nsid
nsid
RP- nsid
Leaked �
Did not Oprn a
Leaked o
RLpairs
and
Materials
Used
,
Test AR,er
DC- Closed
Closed Tight o
Oprned at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
llate last accuracy tested
.._. �-
Cent. Tester No.
Dare
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy