2012_1025CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
lir`���a7ali:iJ.`i
PWS I.D. #
CITY OF COPYELI,
LOCATION OF SERVICE: ,,/�i�/ 5 �G' /chit/ /.= � E//Z
The bacl�low ptzvention assembly detailed below has been tested and maintained as required by TNRCC
rcgulatiotts and is ecruficd to be operating within acccptablc parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle c Pressure Vacuum Breaker
�^-.' Double Check Valve � Atmosphere Vacuum Breaker
1
Manufactstrer � �� Size �
Model Number .���� �� Located At �
Serial Number ��"� /�
The above is certified to be true. /'
Firm Name ` � y`� � // � �� `t ` -�, '/ �/r •�+'ti Certified Tester -
Firm Address =Y C30 _`� '✓ l�[�S�ii -� �' M�1'��! /l�Cert Tester No. � ' � Date
Gauge #
Date last accuracy tested /�- �� -/�
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'A�'R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed_
- Closed Tight �
Opened at
Opened at
nsid
Tight o°
Leaked o
vsid
vsid
RP- nsid
,
��� p
Did not Opm D
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opined at
Opined at
vsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true. /'
Firm Name ` � y`� � // � �� `t ` -�, '/ �/r •�+'ti Certified Tester -
Firm Address =Y C30 _`� '✓ l�[�S�ii -� �' M�1'��! /l�Cert Tester No. � ' � Date
Gauge #
Date last accuracy tested /�- �� -/�
White - Customer's Copy Yellow -City Copy Pink - Testers Copy