2016_0224 (2) .. � � i �.. ,., �., . .. � . .. � � . . .
` IRRIGATION� .r �'OIV�STIC FIRELINE
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The following forrn rr�w�� be completed fo�r each assembly tested: A signed and dated original ,
must be subrnitted to th��►i��l�c water supplier�#'or recordkeeping purposes: , �. _
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BACKFLOW PREVENT�GIN ASSEMBLY TEST AND 1MAINTENANCE REPORT
NAME OF PWS: CITY OF COPP�LL PWS I.D. �#0570040
(Customer) ~�
� MAILING ADDRESS: �C?�'� C'��'-�'f�'�' '�~
CONTACT PERSON/PHONE: °
LOCATION OF SERVICE: � �,;�"'� '�� �'"
The backflow prevention assembly detailed below has been tested and maintained as req�tired by
�'` cornmission regulations and is certified to be operating within acceptable parameters. ' `
TYPE OF ASSEMBLY
'�'.;`�-' ❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detectax
�uble Check Valve ❑Double Check-Detector
" ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker . '
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M,a�nufactur�r ���`� Model Number �� Size�
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�,.� �ted At ��'� ��,..� Serial Number��/� 6.�J � ��
Is�ie as"sembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker '
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� `'� ' Double Check Valve Assembly '` '
� ��a� ; Relief Valve Air Inlet -Check Valve
' \�- 1 st Check 2nd Check
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Held at�psid Held at l• psid Opened at Opened at Held at
r �i�itial Test Closed Tig t Closed Tight sid psid psid
;; �t� � � � Leaked�❑ � Leaked❑ id�notopen ❑ Didnotopen ❑ � �Leaked�` �� � � �i
,�' .:,: airs/ .
Materials j
Used .
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_ ,Helc�at psid Held at psid �
�st After ` Opened at Opened at Held at
pair, Closed Tighf 0 Closed Tight❑ psid psid psid
�" gauge used:Make/Model ���f�'1�'f �'+� SN: ��� � �'
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Test
DateF Tested for Accuracy: ��" ��'� �
Remarks:
The above is certified to be true at the time of testirig. �
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Firm Name�`�'�,Y�}/'��'1�'� �i�I�• Firm A ddress ,� G� ��. `�'�V � �.
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Certified Tester(print) .�,'�i t�,M1���� Certified Tester(signature) '
Firm Phone# ��. �f'l t� Cert;Tester No,� �� � Date �`:� '�"io- � �•
*TEST RECORDS 1�IUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MAN'UFACTURER'S REPLACEMENT PARTS
� White-City Cap� ., Yellow-Customer Copy Pink-Tester's Copy
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