2017_0612 IRRIGATION ,,�_` DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF CO 0040
(Customer) � ; � �
MAILING ADDRESS: %'.�`��� `-x-a '". �-�r�./�' �:�'
CONTACT PERSON/PHONE: • - �;t=:-
LOCATION OF SERVICE: �..">�` �_'-� "_ f��-:•;.�' -'�'-
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
,��ouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker �!Spill-Resistant Pressure Vacuum Breaker
Manufacturer �•�'t 1 �'"✓' `? Model Number ��'`'`t`` Size f'� �.
Located At ��s�¢ '�_�`:�'� �'-' �" �f��'•'�'��"�`�erial Number
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ���
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
��� ]st Check 2nd Check
, f;;.
.-r �� / , ..,
�, = � � Held a���f `"` psid Held at'• " psid Opened at Opened at Held at
Initial Test Closed TightP� Closed Tight � psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open :_� Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
/
Test gauge used: Make/ModeL;%'� "�� tS�``� `� SN: ' ��`-' -�'`t'''`��
�'�,`.
Date Tested for Accuracy: �- f� 'C
Remarks:
The above is certified to be true at the time of testing.
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Firm Nam� Firm Address �� '- u �''''`� - � - r'f
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Certified Tester(print)'''`�z h � "��� "� ��" Certified Tester(signature)` ` '�''�� r„�'--`�-:�p�.._--
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Firm Phone##'�f''� �"'� � �`l �'� Cert.Tester Na��'��+C"-� -� Date � � G '�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy