Freeport NIP(2.4)-LR000928CilECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINI'~IANCE REPORT
TYPE OF ASSEMBLY
Reduc.~ Pressur~ Priuciplc
Double Check Valve
Mauuficmr~
Mod~l Number
Located At
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
REDUCED pRESSURE PRINcwLE ASSElVI~LY PRESSURE VACUUM B~K
Double Check Valve Azs~mhly
Ist t~,el~ I 2nd Check Relief Valve Air
Inlet
Check
Valve
Im~ial Test DC.Closed ~Closed Tight ~ /Opened at Opened at psid
Tighl ~' Le~k~d Q psid psid
R.P- psid
Lcaked r~ Did not Open m Leaked
and
Materials
Used
Te~t After DC-Closed Closed Tight o Opted at Opened at psid
R~palr Tight r~ psid psid
RP psid
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Testur's Copy