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IRRIGATION _ DOM�C_ ' FIRELINE
The following form must be �mplete�,�'or eac�i assembly tested. A signed and dated ori�inal
must be submitted to the publ�cwater supplier for recordkeep�ng purPoses:
,$ACK�LOW P�EVENTION ASSEMBLY TEST qND MAINT�NAN��REPOIt�''
� ' � � � -
NAME O�'PWS: CITY OF CQPFELL •��S I.D #Q579040
(Customer) �
MAILING ADDR�SS:
CONTACT PERS�N/PHONE .��%;� �. s ��.�� ,,,�� � � i"7- ����".��'�`��� �
LOCATION OF SERVICE: �'`L =' � .� �-�"
"The backflow prevention assemb�y detai1ed laelow has been tested and maintained as required by
commission regulations and is certified to be op�ting within acceptable p�rameters.
TYPE�ASSEMBLY
;Reduced Pressure Pr�;ciple iReduced Pressure Principie-Detector
�Cpauble Check Valve 'Doub1� Check-�+efect�r' '
lPressureVacuum Breaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturcr .r` - ,� ._.� Model Numh�r �'�•%'�"" Size �,
;
,�
` d Serial Number '��'f r�� ��� .%�
Located At %��� ����� �� "��r` ���.,�'' �
Is the assembly alled in accordance with r�t�ufacturer recommendations and/or local codes� ��- '��
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at ��`�" p� Held at=�psid Opened at Opened at Held at
Initial Test Closad Tight�`'' Closed Tight °�-'���� psid psid psid
Leaked' 1 Leaked;1 id not open i I Did not open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test Atter Opened at Opened at Held at
Repair Closed Tight � Closed Tight I '� psid Ps�d ps�d
SN: �..�.�/✓,� °�`,
Test gauge used: Make/Model r��k�f'�= ��-z� -J�r>ii ` 'f `
Date Tested for Accuracy: �" `'� "1.�;�r
Remarks:
The above is certified to be true at the time of testing.
� FirmName ,�;� �'� ���;�z- .�" Firm Address � ��`� � � 1� � � �'���
4�
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Certitied Tester(print) �'� � � �� �' Certified Tester(signature)���-.�- ���
� , _,. .. � � Cert.Tester No.�f'e,� 4 `��� Date -�,;'�:..�,�-
Firm Phone# ��• �. -�,� —
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
V1/hite- City Copy Yellow- Customer Copy Pink-Tester's Copy