2015-1016 (5) IRRIGATION DOMESTIC v ftRELINE
The following form must be completed fiir each assernbly tested. A signed and dated original
must be submitteci to the public water supplier for recordkeeping purpases:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAI9YTENANCE REPORT
NAME OF PWS: C[TY OF C�PPELL PWS I.U. #0570040
(Cust'omer} f�
MAILING ADDRESS: l"/�x�.-,�, <<,��S�C �,a�.r�����pt� A I�L . ��c, 76 0l l
CONTACT PERSON/PHONE: � � �j�_ -� � ..
LOCATION OFSERV[CE; ///�o �qr£C,,, � , _
The backflow prevention assembly detailed below has be�a testec!and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
- Reduced Pressure Principle '--':Reduced Pressure Principle-Detector �
�oubleCheck Valve 'Double C:heck-Detector
-Pressure Vacuum Sreaker �i Spill-Resistant Pressure Vacuum Breaker
Manufacturer �atiL�- Model Number_ fU�yl,i/ Size Z°
Located At�L�� �A.�.�it� Serial Number .rs��J /
Is the assembly installed in aecordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaicer
Double Gheck Valve Assemb(y
Relief Valve Air[nlet Check Valve
t st Check 2nd Check
Held at�ps Held at. �' T psi Opened at___ Ope�ed at Held at
Initial Test Closed Tig� Gosed Tight i psid psid psid
Leaked l ' Leaked i id not open I, Did not open I Leaked '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight: Closed Tight ' P$�d psid psid
Test gauge used: Make/Model �✓uGfh�.� "Tt�S' SN: O 7a�o'f��
Date Tested for Accuracy: �-lv�/S
Remarks:
The above is certified to be true at the time of testing.
Firm Name ��- �+�-�-- �itiS' Firm Address �� (3� 7 97 /��-, �, -�f-�r"/6B
Certified Tester(print) �4 ��� ��.� Certified Tester(si�nature) �
Firm Phone# �va--S.�U—Zy�'7 Cert.Tester No. 3P va'b d/S 1 Date /�� /6'/j'
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Custamer Copy Pink-Tester's Copy