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2017_0601 - . .,�.._,. �,� ,. �. , ,,s .�->''�� .. _;, .. . : , ►4Y ki.`. . ' •,�: ..' �. ,w*,... . . �. . . . �-. .,.,... .. .. � . . uM.%i.,y .--. ERRIGA�'ION Y ' DOMESTIC ,�. FIRfLiNE _ The following form must be cc>mpleted for each assembly tested. A signed and dated original - ' must be submitted to thc public��ater supplier for recordkeeping purposes: .... .., . ` , ' ..:i . . ._......�:<'. �'"� : - . BACI�FLOti�'PRE�'E:�T10:�ASSEMBL� TEST AND�1AI1TE\A�CE REP(3RT ,. _.. ,�w� .:,,�. . .. � .-� � �NAME OF P��VS: CITY OF E`OPPELL PWS t.D._#0570040 - � ...�.�. �........... . .. .. `-� � � �K�. j�ustomer)....,... . _._�, .,�... . _:.,��;.,, MAILING ADDRESS: �`�_."�` _ �', _._��--. _�_.______ __��_ CON7ACT PERSON/`PHONE: K�d��- U64'338�Z!99 -- ------- —_— _ _,__...—_•-�-, LOCATION OF SERVtCr: ?2 9 {-�a.w►r�+�n � The backflow pre�ention assernbly detailed belo�� has been tested and maintained as requircd hy commission regulations and is certitied to br oprrating�ti•ithin acceptahle parameters. r,� ; . �. : :�,�: �''�.�:»,,�,, ..... TYPE OF.�iSSEMBLY' _.. ��.: Reduced Pressure Principle Rcduced Pressure Principle-Dctector �-`� ..y V. �oubJeCheck Va�v� _ . I)ouhle Check=�etector 4_ . �.., t�- ' " � � Press�re Vacuum L�reaker Spill-Resistant P�ssure Vacuu�Breaker �'�'� ,� ,,-. Manutacturer �1 LC.:r► S Model Number 3"S O Size 3 ��/ ,.'' „ :_---___ _ •- � _;. .`'. Loi.�`ated At +�`vn�_�/�.1� ___ _ _ Serial I�umber��_3S 7 Is the assctnbly installed in accordanre�t�ith ►nanufacturer recommendation5 and,'ur local codes'' Rcduccd Yresstire Princi le Assemhlv Pressure Vacuum E3reaker _�Dot�ble Check Val��c,4ssemhlv Rclief Val��e Air Inlet Check Valve I st t'heck ?nd Check -' l leld at 2'6—p�id t lelcl at .2•2 p�id (:)prned at (7pened at Hetd at Initial Test C�lose�T ight� C'losed Tight �� psid psid psid . Leakcd Lrakcd Did not open Did not oprn l.eaked R�,paus .. .�.�..,, . �,� � i�I'�tenats °� � L'sed : _��,:.. � H�ad at__psid Held at psid � � �� Test After - Opened at Opened at H�Id at Itepair C�I��sed Tight Closcd Tight p�i� psid -- psid � — Test gauge used: MakeiModel_ Co��.___ 4�tLoo �5w SN:v?-�4 S 69 �"- .�ate_Testcd li�r,Acc:ui•acy: t o-Z-1 � 4— ___ - -- ------. - ---- w=- Remarks: �'h�: above is certitied to be true at the time of testing. � ^ Firn�Narne�¢wn _L.�g_u-�� _____.Firm :'�ddress P.0, �t�� _l�b �dyS4 G f+j T� Certitied Tester(print)_�d��t LtR.��. _. Certitied Tester(signature) •�-- ___ Firm Phone#_�l[�,q,33g_2��__Cert.Tester No. v12�F'Z _pate �/ 7 _ *TEST RGCORDS MUST BE KEPT I�OR AT I_EAST T�iRF,F.. YEARS **USF.ONLY MANUFACTURER'S R[:PLACEMF.NT PARTS White-City Copy Yello�v-C'ustomer Cc�py Pink- Tester's Co�y , � ��. .,, �,.