2014_1010 . . ., . i
I
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
rraME oF Pws: cITY oF coPPEi�
PWS I.D. # '
LOCATION OF SERVICE: �>2� C_..��v�b C �r
The bacl�low prevmtibn asscmbly detailed below has beea tested and main ain� � nq�� �, �CC
re_guladons and is cercified to be operaring withia accrptable paramcters.
TYPE OF ASSEMBLY i
� C Reduced Pressure Priaciple C Pressure Vacuimm Breaker ;�
'� Double Cheek Valve a; , � � Atmosphere Vacuum Breaker
r `
Maaufact�uer �w--z.� Siu �
Model Number �-�-���'J Located At 1 b7 C C_o 1 a�..��_7l
Serial N�ber (ri 5 5 00
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BItEAI�R
Double Check Valve Assembly '
ist Check 2ad Checl: Relief Valve Air Inlet Checic Valve
Inival Test DGClosed Closed Tight �- Opeaed at Opened at �sid
�,
Ti � Leal:ed O nsid __nsid
��> �- •?- Ds�a l - �
Leal:ed o � Dia noc Opea o L,ealced o
�P�
aad ,
Materials
� , U� , � �� . _.w : ,�
Test Aftet DC-Closed Closod Tight o Opened at Opme�at _nsid
Repair Tight o �sid _osid
R.P sid
The above is catifiod to be true.
Fiim Name �ti�s�� �c Certifiod T
� �,,� , r�n :��-.
Firm Address k _tia� � �',��,U� Cert. Tester No. ' ?3 Date ,:-1 c�-1
Gauge # _��1 I��2`�to�
llate last accuracy tested �-2 �r)�
White- Customer's Copy Yellow - City �opy Pink-Tester's Copy
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