2015-1016 (8) IRRIGATlON � DOMESTIC FBRELINE
The following form must be completed fvr each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PRE VENTION ASSEMBLY TEST AND MAI�ITENANCE REPORT
NAME OF PWS: CITY OF CQPPELL PWS [.D. #0570040
(Customer) �
MAILING ADDRESS: R o r� (�Ob S � p �, ���1� ,
CONTACT PERSON/PHOd�TE: ��
LOCATIOl�i OF SERVICE: ///� EecQ,��
The backflow preventian assemhly detailed below has been tested and maintained as nequired by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSE.MBLY
:-'Reduced Pressure Principie '--Reduced Pressure Principle-Detector �
✓�oubleGheckValve !Double Check-Det�ctor
^'PressureVacuumBreaker - Spi1l-Resistant Pressure Vacuum Breaker
Manufacturer �i✓�� Model Number (�lJ�Jy�l,l Size G ��
Located At�� �-�/�� S�'�� Serial Numbc;r ��/.� �
Is the assembly instailed in accordance with manufacturer recommendations and/or lUcal codes?
Reduced Pressure Princi le Assembi Pressure Vacuum Breaker
Double Gheck Va(ve Assembly
Relief Valve Air[nlet Check Valve
1 st Check 2nd Check
Held at �.� ps3d Held at�psid Opened at __ Opened at Held at
Initial Test Closed Tight"� Closed Tight 1/ psid psid psid
Leaked; ; Leaked ' ed not��n i Did not open ' Leaked:
Repairs/
Materials
Used
Held at psid Held at psid
Test After fJpened ai Opened at Held at
Repair Closed Tight' ; Closed Tight. �SI� psid psid
Test gauge used:MakefModel--���r�"- � -S—' SN: "D 7�Qv�'�-g�
Date Tested far Accuracy: lo` /�— /s'
Remarks:
The above is certified to be true at the time of testing.
Firm Name �� !�I� ��S Firm A ddress fl ���f�,.�, /� "7 5 J�B
Certified Tester(print)��,,,,�'t� Cjo�,�ertified Tester(signature)_
Firm Phone#_ �Ua-S-5 0�z2�� Cert.Tester No. �}P�'D �i):S 7 Uate_��y J�/!�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANIJFACTURBR'S REPLACEMENT PARTS
White-City Copy Yel(ow-Custamer Gopy Pink-Tester's Copy