2011_0422 (23)CHECK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACKFT�OW 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 TCl✓Q
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure PrinClt)le � Pressure Vag- I]L�T31 Breaker
C-3 Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
_, -
Modes Number Located At � r
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
p, :.
Date Iast accuracy tested � ',
Certified Tester °
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI�LBLY
PRESSURE VACUUM BR>F',�T�'R
Double Check Valve Assembly
1st Chekl:
2nd Chek:
Relief Valve
Air Inlet
Check Valve
p
Initial Test
DC- Closed
Closed Tight D
Opened at
Opened at
osid
Tight � �
Leaked o
psid
osid
RP- osid
Leaked �
Did not Open D
Leaked o
Repairs
and
Materials
Used
Test AS%r
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
p, :.
Date Iast accuracy tested � ',
Certified Tester °
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy