2011_0812 (6)CIIECK ONE.
IRRIGATION
DOMESTIC ef_ FIRELINE
BACi�'LOW PREVENTION ASSEMBLY -TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPE'LL
PWS I.D. #
LOCATION OF SERVICE:
The bacicilow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acccptablc parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Va�-+�•**+ Breaker
� Dotiblc Chccic Valve � o Atmosphere Vacuum Breaker
Manufactaffer
Model Number
Scrim Number
Size
_•_ . 4•
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date lest accuracy testes
Certified Tests
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFATCFR
Double Cbec3c Valve Assembly
1st Check
tad Checi:
Relief Valve
Air Ides
Cheek Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Tight a
Leaked �
nsid
osid
RP- osid
Leaked o
Did not Opm o
Leaked �
Repairs
and
Materials
Used
,
Test After
DC- Closed
Closed Tight o
Opeaed at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date lest accuracy testes
Certified Tests
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy