TEST & MAINTENANCE REPORT BACKFLOW PREVENTION ASSEMBLIES NAME OF PREMISE: STREET ADDRESS: LOCATION OF DEVICE: SERVICE: POTABLE FIRE IRRIGATION OTHER Manufacturer: Model: Serial No.: Size: RP DC   PVB AVB AG    PRESSURE DROP ACROSS FIRST CHECK VALVE PSI CHECK VALVE #1 CHECK VALVE #2 DIFFERENTIAL PRESSURE PRESSURE VACUUM RELIEF VALUE BREAKER INITIAL 1. LEAKED 1. LEAKED OPENED AT AIR LBS. INLET OPENED AT   TEST PSI 2. CLOSED TIGHT 2. CLOSED TIGHT DID NOT OPEN DID NOT OPEN     CLEANED CLEANED CLEANED    REPLACED: REPLACED: REPLACED: CHECK VALVE: PSI RIBBER PARTS KIT RIBBER PARTS KIT RIBBER PARTS KIT LEAKED     C. V. ASSEMBLY C. V. ASSEMBLY C. V. ASSEMBLY    OR OR OR CLEANED  DISC DISC DISC    O-RINGS O-RINGS O-RINGS REPLACED:    R SEAT SEAT SEAT C. V. ASSEMBLY     E P SPRING SPRING SPRING DISC. AIR INLET     A I STEM/GUIDE STEM/GUIDE STEM/GUIDE DISC. C. V.     R S RETAINER RETAINER RETAINER SPRING     LOCK NUTS LOCK NUTS LOCK NUTS RETAINER     OTHER OTHER OTHER GUIDE     O-RING  OTHER  FINAL CLOSED TIGHT CLOSED TIGHT OPEN AT LBS SATISFACTORY    TEST REDUCED PRESSURE NOTE: ALL REPAIRS/REPLACEMENT SHALL BE COMPLETED WITHIN TEN (10) DAYS. REMARKS: I HEREBY CERTIFY THAT THIS DATA IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OF THE UNIT. CERTIFIED TESTING COMPANY: INITIAL TEST BY: CERTIFIED TESTER NO. DATE: REPAIRED BY : DATE FINAL TEST BY: CERTIFIED TESTER NO. DATE:
TEST & MAINTENANCE REPORT BACKFLOW PREVENTION ASSEMBLIES NAME OF PREMISE: STREET ADDRESS: LOCATION OF DEVICE: SERVICE: POTABLE FIRE IRRIGATION OTHER Manufacturer: Model: Serial No.: Size:  RP  DC  PVB  AVB  AG PRESSURE DROP ACROSS FIRST CHECK VALVE PSI CHECK VALVE #1 CHECK VALVE #2 DIFFERENTIAL PRESSURE RELIEF VALUE PRESSURE VACUUM BREAKER INITIAL TEST 1. LEAKED  2. CLOSED TIGHT  1. LEAKED  2. CLOSED TIGHT  OPENED AT LBS. DID NOT OPEN  AIR INLET OPENED AT PSI DID NOT OPEN  R E P A I R S CLEANED  CLEANED  CLEANED  REPLACED: REPLACED: REPLACED: CHECK VALVE: PSI RIBBER PARTS KIT  RIBBER PARTS KIT  RIBBER PARTS KIT  LEAKED  C. V. ASSEMBLY  C. V. ASSEMBLY  C. V. ASSEMBLY  OR OR OR CLEANED  DISC  DISC  DISC  O-RINGS  O-RINGS  O-RINGS  REPLACED: SEAT  SEAT  SEAT  C. V. ASSEMBLY  SPRING  SPRING  SPRING  DISC. AIR INLET  STEM/GUIDE  STEM/GUIDE  STEM/GUIDE  DISC. C. V.  RETAINER  RETAINER  RETAINER  SPRING  LOCK NUTS  LOCK NUTS  LOCK NUTS  RETAINER  OTHER  OTHER  OTHER  GUIDE  O-RING  OTHER  FINAL TEST CLOSED TIGHT  CLOSED TIGHT  OPEN AT LBS REDUCED PRESSURE SATISFACTORY  NOTE: ALL REPAIRS/REPLACEMENT SHALL BE COMPLETED WITHIN TEN (10) DAYS. REMARKS: I HEREBY CERTIFY THAT THIS DATA IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OF THE UNIT. CERTIFIED TESTING COMPANY: INITIAL TEST BY: CERTIFIED TESTER NO. DATE: REPAIRED BY : DATE FINAL TEST BY: CERTIFIED TESTER NO. DATE:
WAIB-010%20Water%20Backflow%20Prevention%20Program%20x.docx