BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE …

BACKFLOW P REVENTION ASSEMBLY TEST & MAINTENANCE REPORT Customer Name: Mail ing Address: City State Zip: SERVIC E LOCATIO N: ASSEMBLY LOCATIO N: MFR: MODEL: SERIAL # TYPE: LINE PRESSURE: INI TIAL TEST CHECK VALVE 1 HELD AT ____ PVB _____ RP PRESS DP __ LEAKED _ _____ CHECK VALVE 2 HELD AT _ ____ . _____ RP TIGHT _ _____ LEAKED _ _____ RELIEF VALVE __ PSI DID NOT OPEN _____ AIR INLET OPEN __ PSI DID NOT OPEN _____ REPAIRS CLEANED _____ REPLACED _____ DISC _____ SPRING _____ GUIDE _____ HINGE PIN _____ SEAT _ ____ MODULE _____ OTHER _____ DESCRIBE: CLEANED _ ____ REPLACED _ ____ DISC _____ SPRING _ ____ GUIDE _____ HINGE PIN _____ SEAT _ ____ MODULE _____ OTHER _____ DESCRIBE: CLEANED _ ____ REPLACED _ ____ DISC _____ DIAPHRAGM _ ____ FLOAT _ ____ SPRING _ ____ OTHER _____ O-RING(S) _____ MODULE _____ DESCRIBE: CLEANED _ ____ REPLACED _ ____ DISC _____ DIAPHRAGM _ ____ FLOAT _ ____ SPRING _ ____ OTHER _____ DESCRIBE: FINAL TEST CLOSED TIGHT _ __ CLOSED TIGHT _ __ OPENED AT __ PSI OPENED AT __ PSI COMMENTS: THE A BOVE R EPORT IS CERTIFIED TO B E T RUE.

final test after repairs print name tester cert # date TESTER’S COMPANY NAME TESTER’S PHONE NUMBER ONLY CALIFORNIA DEPT.

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  Tests, Prevention, Maintenance, Assembly, Backflow, Backflow prevention assembly test amp maintenance

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