2011_0718CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE � � /
BACKFT�OW PREVEN'T'ION ASSEI��LY TEST AND MAINTENANCE REPORT
NAME OF PwS: CJTY OF COPPEI_L
PWS I_D_ #
LOCATION OF SERVICE: = � -' --
The bacidlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is cea-tified to be operating within acceptable parameters_
C Reduced Pressure Principle
�" " Double Check Valve
Manufacturer `'° \ �, �� ty -
Model Number
�- -;, � .;
Serial Number f r r � 1 1
TYPE OF ASSEMBLY
e Pressure Vacuimm Breaker
o Atmosphere Vacuum Breaker
�� �.�
Size
Located At � �," r, ", ` P . 1 .- _
The above is ceatified to be lave.
Firm Name '� ; � �. � � � ; ° � j,. _ �,, � r -T ( "r �.
Certified Tester
Firm Address Cent. Testa No. ' � � , ' ' t � ` Date / � ,
_ _ - -_ _ -,
Gauge # � , i ! s''1 -1
Date last accuracy tested � �" �' �
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFLAF�R
Doubie Cheek Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
�, � i �
DC- Closed
Tight �
�- � �` osid
��� o
Closed Tight SL
Leaked �
�7
Opened at
Dsid
Opined at
osid
Did not Opm o
osid
Leaked �
RePaiT�
and
Materials
Used
Test ARa
Repair
DC- Closed
Tigitt o
Closed TiQ�. ht O
Opined at
osid
Opined at
osid
osid
RP sid
The above is ceatified to be lave.
Firm Name '� ; � �. � � � ; ° � j,. _ �,, � r -T ( "r �.
Certified Tester
Firm Address Cent. Testa No. ' � � , ' ' t � ` Date / � ,
_ _ - -_ _ -,
Gauge # � , i ! s''1 -1
Date last accuracy tested � �" �' �
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy