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2014-1111 .. , , .. .. � } C�IECK ONE: ; IR.RIGATION DOMESTIC FIRELINE BACKFLOW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPORT ; , � f NAIv�QFPWS:: CITYOFCOPP�'LL ��`��lr2��`( � C�UC�TI�:t ��"�!�C��` ' �. � , - �_, . ' � ""'�,,*..; PV�/S LD:�# � f ' _� ` � p � : �f ' LOCATION OF SERVICE:: �� `'�� C ��i7� �n lQ.�/W�,`t' '� . ,.-. . � -�- >� The bacl�low prevmtion assembly derailed below has been t�sced and maintain� � nq�� , '�CC regulauons and is certified to be operating within ac,ceptable paramcters. TY�E OF ASSEMBLY C Reduced Pressure Principle ��,�� ❑ Pressvre Vacu�Breaker � uble Check Valve o Atmosphere Vacuum Bnaker Maaufact�aer ��J Siu � +1 Modei Nimmber �,�� =T� Located At �.��tr. '`� �7�"� 1�-�M , Serial Nimmber 'V� `.� p �I�`� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R Double Check Valve Assembly lst Check ?nd Chec�: Relief Valve Air Inlet Checic Valve . Inival Test DC-Closed Closed Tight � Opened at Opeaed at nsid Ti �1 Leal:ed o �Dsid _osid � RP��.psid � Q ��75 Leal:ed o � Did not Open o L,eal:ed � RePairs ` � . Mataials Used . _ Test Aft,e� DC•Closed _ ___ Closed Ti�t o Qpened at Opeae�at ,�sid_ Rtpair Tight ❑ osid __osid RP sid The above is cati6od to be tive. , r. - �„�--- Firm Name� �`��k. � �T`C_ Cerafiod Tescer � �� L I �" �2�( Firm Address 't��.�l��`J ��= Cat Tester No. ��q�Date �� , Gauge # �� llate last accuracy tested !� �, � White - Customer's Copy Yellow - City Copy Pink-Tester's Copy