2011_1118 (5)CHECK ONE:
IRRIGATION DOMESTIC FIR ELIN E
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. CITY OF COPPELI. _
PWS I.D_ #
LOCATION OF SERVICE:
The bacldlow prcvmtion assembly detailed below has been tcsttd and maintained as required by TNRCC
rceulacions and is ca-tificd to be operating within acctptablc parameters_
TYPE OF ASSEMBLY
C Rtduccd Pressure Princiolc C Pressure Vacuum Breaker
Double Check Valve n Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is ccrafied to be trot.
Firm Name
�.. ... tom_ .
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No_
Date
White - Customer's Copy Yellow -City Copy PinK - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAi.'FR
Double Check Valve Assembly
1st Cheki:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tilt D
Closed Tight d
Leaked O
Opined at
osid
Opined at
osid
osid
RP- osid
Leaked o
Did not Opm O
Leaked �
Rcpaus
and
Materials
Used
Test Auer
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tight n
osid
osid
RP sid
The above is ccrafied to be trot.
Firm Name
�.. ... tom_ .
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No_
Date
White - Customer's Copy Yellow -City Copy PinK - Tester's Copy