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2016_0517 4 I �p�� `� -. �rA: C 1 } ..JE'�� "0.�`� ... 4� . ... � � � . .�� .� etP�' .. .� . . � _.�a,y . � . I IR�tIGATION :' z � f � , � DOME�TIC ^ �FIjiELINE .;s'`. . . . � ... ,�� � :� },4. �.. , i , ? . �� :, ._.,. .: . . . . The following �o�'must : �ca�npleted for each assembly tested: �i `si�ned�:and dated original must t�e submitte o the publ�ic�ate�suppliex.for recordk�eping puipose�;�a '�; � � , ; B�CK�'''LOW PREVENTI�DN ASSEM$LY TEST AND MAINTENANCE REPORT , � i � NAME�F'PWS: CITY 0F CO�'P.,LL FWS I.D. #0570040 , � (Customer) , . `'` MAI�,ING ADDRESS:''1 . � ,�,� ,�'�,� �- +� . /� "µ " ""' / , ,.LrJ�� r i .I��r}a,E L� �,+� � ��""�e u`'7 �4 a.+�t���...+MrM . . . CQNTACT FERSfJNfPHONE: G ' . . 4 � LEI�ATION OF��RVICE: - �� 1-,C�,,,. ��. .,, The backflow reve�tion assembl deta led below has been tested and maintained as rec�uired by � 6 �___._�._�_ _._,....�.-. � .� � ;�. p Y � -�e�tltlt'rs5ie�-re�tlati�tis�t�i5-e�i�et��ii�er�g vait��.�cce�tahle p�.tameters. . ... � _ � .�, . __�_ ��r�...a.._ .____.,._. , � ,: ---� .. �, , TYPE bF ASSEMBLY �, ° f ,._ - > '., , �Re�d ced'Pressure Principl� ❑Reduced Pressure��'rinci^p�-Det,�ctor C�B�ubleCheckValve ❑Double Check-Det"ec�or "� ' � ❑PressureVacuumBreakerl ❑Spill-Resistant Pressiire Vacuum Breaker ' ' � � , � � " . � � S " .,�. .. � � �, � Mantafacturer 1�-� �e" ��c � � Model Number ize_�_ _ L�ca;ted.At �.�t r� � ���,., si�:,��.. � �,'� �/'�."? ( �>; j�. U � Serial Number ,;" - � � . v., ��� �,m _ ;, Is tlie assetnbly installed in accordane�with manufacturer recommendatians�nd/�ar}ocal ,codes? ��' � ' � � ;, � „ ,F ,,; ' - ,Iteduced Press e Princi le i�s�mbl �ressure Vacuum Breaker `° , 1 ,� ,:� �� ,� �� � . Double Che�k V�lve A sembl}+v- ? , � ' ��,, � al Air Inlet Chec Vad�ve" , -. . . .; � Relief V ve ` ' �f Chect� 2�td�hec ' �t ' , �., � � . , � � , , ;.� ��.. _,,.� , ,,. ,� , � � � N. �, � � �, � i T i f' '�. f ' �ld at�'; N*�s�d Helc��t�� ned at fl ened at Held at ,_ ��-� - , _. , , ,. a _�. ,r , . . _.. _.. . . - �� ,. � / � "��•' -s�� - e � i� ' r , I�iitia�T��t C�' sed Tight� Clo�ed Tight``� psid � psid f`' psid '� , _ � �� �.�kedC�;,� L edCl, id not open ❑ Did ndt open ❑ Leaked�> Repaits! "�, ,`; , ' , � Mater�a�� " `x 'a ' k � ��, � , � • , �.T : , i � � ��. '��� �He t�at. ���psid I��C� 'at�� �psid ��� � � ��� � � � �. � ' �i ' t A� �s �� Ogened at Opened at�� Hetd at�r;. ! � �� � �Clc��ed Tig�t❑ �lo d�'ight❑ p��d � psid � � psid ° � ` °`� I � ,'��. � �y� � � .� .. ... :�� Test.gauge�ed. ��I�ke/l�odel �.����`���t'�� 5N:' �..%� ��` ��r� � '4 ' , r � �-=;�.. ; Date'Tested f�r A��uraey.:. �'- �' �p`�;.�' " x '�. Re'xt"iarks: '�� " �'� p�. .;. . 4 � . . A' . _,.._ •" . . �p.-1 -.a�G...:.+..+-.ar� � ,�......�:i "� a F,—"..-'+s+-.P4�DAd1ia J " - ; ��.. 1 _ __ � p ryi � �� ��`T�t� abo�is��c�rti� fo�e�t�e��t�,t� �ri�`�r�`t�'n� � � � � �� � � . . e�/i �. . { ,� �., . �y t nx ' ,� ` � �.. { . �°fl F • � � 1 Firm Name ��`�:���r#�"'�� ��.�_�������?'���.' Firni Address �x �"��"'�_ '�"`'�.�:���^���°,,'.�';�.�`"��% �` ,`� '��� ' � � ; 'y � , . ��—�' ' ; _ `� �� /� �j tl, Certified T��ter(print) �` ` �. '�:'"�y��.'���'�'�,.-;. Certified�'ester(signature) � +�,:� �'� F��I�✓'' -;, ' � � , . � . , _� � ;:�. , r � �, � ��'^� 4 �. .. _ � , � / Firm����hone#_.. �� ��� Cert.T�ster No.� � �,�;�,:� ..` � ,��I�a't�.°""�: 1��' �!"' � � . � �� , � � � � � ,_� ,� . � ;;. � � *TEST REC�RI�S MUST BE KEP��'OR�T L�AST THREE Y�ARS � . . , ° : **USE ONLY MANUFACTURER'��EPLACEMENT PA1�TS;, ' 1,� f� � f, i >. . ,, .r . , .. , _ � ; , � � � � . � s. �,� � �� � -,; - � : •: � � `4 White-Gity�Copy �� �� `��e11dw-�C�r Copy :." ' , �' #�'ink""�ester's Cop���. �' ,� ' .', � � , �, , " � ^ � r� x ! ` . \ ' , - - __ . , , { .. ,:, �` ,, ` .. u ,-�-�.. � ' �..a,e.,a,�..�1... ...:: ,. �, _. . � t '. t- _ . t . o ... „_ _ . _ � . ,,