Test And Maintenance Report

Section

Account Number:

Customer:

Mailing Address:

Street Address:

Location of Assembly:

Section

Type of Assembly:

RP

DC

PVB

SVB

Size

If RP, Relief Valve Clearance

Assembly Manufacturer:

Assembly Model No.:

Assembly Serial Number

Test Kit Serial Manufacturer

Test Kit Serial Number:

Calibration Date:

Check Valve No.1

Leaked

Closed Tight

Gauge pressure across check valve ____ PSI:

Cleaned Only

Replaced:

Gauge pressure across Chech Valve ____ PSI

Relief Valve

Opened at ___ psi

Or

Did not open

Outlet Shut-off Valve:

Leaked

Closed Tight

Cleaned Only or

Replaced:

Relief Valve Opened at ___ psi

Check Valve No. 2

Leaked

Closed Tight

Gauge pressure across check valve ___ psi

Cleaned Only or

Replaced:

Gauge pressure across Check Valve ___ psi

Pressure Vacuum Breaker

Air Inlet

Did Not Open

Opened at ___ PSI

Check Valve

Did Not Open

Opened at ___ psi

Cleaned Only or

Replaced:

Air Inlet ___ psi

Check Valve ___ psi

This Assembly:

Passed

Failed

Remarks:

Section

Printed Name

Date:

Email Address:

Section

Certification Number:

Tester Telephone Number

14617 Perkins Rd.

Call us:

Section

Section

Check Valve No.1

Relief Valve

Check Valve No. 2

Pressure Vacuum Breaker

Section

Section

Courses & Training

Resources:

Other Services