2015_0121 C�IBCK ONE:
.--.
IRRIGATION /� DOMESTIC � FIRELINB
BACIQ�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAI�OF PWS: CITY OF COPPEI�
PWS I.D. #
LOCATION OF SERVICE: � � � �- �i �,�.. f7.� s
The back-flow preveation assembly detailod below has beea tested aad maintair� � nq� �, 'I'NRCC
regulanons and is ceraified to be operadng within accrptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle � Pressure Vacu�mm Breaker
:�� Double Check Valve o Amiosphere Vacuum Breaker
� !?c�-J
Manufactiaer I- � Siu �I'-r
Model N�ber �':* � Locaud At �� �'•1 ��. ��'� ��,.� �v P tJ� � �:�
s«��N�ba 1-� � v����
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAKER
Doubie Check Valv�Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DC-Closed Z c' losed Ti;ht Opened at Opened at nsid
Tight Leal:ed o nsid __,osid
RP-_psid 3 `a �
Leal;ed o Did not Opea o Lealced �
RePairs
and
Mataials
Used
Test After DC-Closed Closed Tight o Opmed at Opeaed at _�sid
Repair Tight o �sid _,osid
RP sid
The above is cerrificd to be true.
Firm Name �1���r��t� ���'C� �')<� '�,(�F:4.�c,�Certified Te.sta 1�� %` ��''.�, �,,r ;.;i Y,�__..
Firm Address �� ��. x '��'�� %�:� �1 Cert.Testc No. �.�'1 f�,� a �- Date ) - Z ' >>
�,� ,� � � � �ti `�r �r',e 1 � I, .
I y �
Gauge # �,�� �� ,�,`��y �;��
Date last accuracy tested �:� � �=° i{%
White- Customer's Copy Yellow - City Copy Pink -Tester's Copy