Spreadsheet: 7157d28c-f270-4405-8bfe-13ff105e637c
Sheet: Sheet1

Water Programs
3200 Civic Center Circle NE
Rio Rancho, NM 87144
Phone: (505) 896-8816       Fax: (505) 891-5201
[NAME]
Customer Information
 |  |  | Owner's Name: | _____________________________________________________ |  |  |  |  |  |  |  |  |  |  |  | Phone: | ________________
 |  |  | Premises Name: | ________________________________________________________________________________
 |  |  | Address: | ________________________________________________________________________________
 |  |  |  |  | Customer's Representative: | ____________________________________________ |  |  |  |  |  |  |  |  |  | Phone: | ________________
 |  |  | Water Meter No: | _______________________
Assembly Information
Current Assembly Information |  |  |  |  |  |  |  |  |  |  |  |  |  | Removed Assembly Information
 |  | Manufacturer: |  | _______________ |  |  |  |  | [NAME]: |  | _____________ |  |  |  |  | Manufacturer: |  | ______________
 |  | Model: |  | _______________ |  |  |  |  | Serial No.: |  | _____________ |  |  |  |  | Model: |  | ______________
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]: |  | ______________
 | O | Containment: |  |  | O | Domestic |  | O | Irrigation | O | Fire Protection |  |  |  |  | Serial No.: |  | ______________
 | O | Isolation: |  |  | ___________________________________
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Test Gauge Information
Physical Location: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Manufacturer: |  | ______________
________________________________________________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Model: |  | ______________
________________________________________________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Serial No.: |  | ______________
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Last Cal: |  | ______________
[NAME]? |  |  |  |  | O | Yes |  | O | No | O | N/A
Test Information
 |  |  |  | RP |  |  |  |  |  | DC |  |  | Test Results |  | O | Pass | O | Fail
 |  | CV1 AR |  | ______ |  |  |  |  | CV1 | ______ |  |  | Test Type: |  | O | Initial | O | Annual | O | Repair
 |  | RV |  | ______ |  |  |  |  | CV2 | ______ |  |  | Test Date: _____________ |  |  |  | Time: __________
 |  | [NAME]? |  | ______
 |  | CV1 CR |  | ______ |  |  |  | O | PVB | O | SVB |  | Comments/Repairs:
 |  | CV2 |  | ______ |  |  |  |  | AIV | ______
 |  | Buffer |  | ______ |  |  |  |  | [NAME] | ______
Technician/Employer Information
I certify that I have tested the above assembly in accordance with the City of Rio Rancho Backflow Prevention and  Cross Connection Control Ordinance, and that the information is accurate to the best of my abilities.
 |  |  |  | Technician Name: | __________________________________
 |  |  |  | Employer: | __________________________________
 |  |  |  | Employer Address: | __________________________________ |  |  |  |  |  |  |  |  | __________________________________
 |  |  |  |  | __________________________________ |  |  |  |  |  |  |  |  |  | Technician Signature
 |  |  |  | Phone: | __________________________________
 |  |  |  | email: | __________________________________ |  |  |  |  |  |  |  |  |  |  | RR Registration No.: | _______________
Rev. 11/2013