2012_0525 (3)CIIECK ONE:
IRRIGATION DOMESTIC FIR ELiNE
BACKFT,OW PREVENTION ASSEMBLY 'PEST AND MAII�7'I'ENANCE REPORT
NAME OF PWS: CITY OF COPPL'LL
PWS I.D. #
LOCATION OF SERVICE: _ /C� S= /i- /f /iir /.�,/. ��-�! ��,rr /� ice' %�� %`%
The bacl�low preveation assembly detailed below has bees tested and ma;nra;ned as requirzd by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle L-� Pressure Vacutmm Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
,.
Manufacturer '`'_ Sizc
Model Number � a .' Located At � -��-
Serial Number ` '`
The above is certified to be true.
Fitm Name -> - - - � Certified Tester
Firm Address � Cert Tester No. . Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR -_r��R
Double Check Valve Assembly
1st Cher:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight C7
Closed Tight D
Leaked �
Opened at
nsid
Opened at
nsid
- nsid
RP- nsid
Leaked [7
Did not Opea a
Leaked �
Repairs
and
Materials
Used
Test Ai%er
Repair
DC- Closed
Tight Q
Closed Tight o
Opeaed at
nsid
Opined at
nsid
nsid
RP sid
The above is certified to be true.
Fitm Name -> - - - � Certified Tester
Firm Address � Cert Tester No. . Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy