Backflow Prevention Assembly Test And Maintenance Report Page 2
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2Test gauge used: Make/Model_________________ SN:_____________
Date Tested for Accuracy: __________________
Remarks:____________________________________________________________
The above is certified to be true at the time of testing.
Firm Name ________________________Certified Tester (print)___________________
Firm Address _______________________Certified Tester (signature)________________
Firm Phone #_____________________Cert. Tester No.___________Date___________
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
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