2012_1025CIIECK ONE=
IRRIGATION
DOMESTIC
FIRELINE
BACT{FI,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS
CITY OF COPPELI
PWS I.D. #
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL7UM BREAi�R
Double Cheek Valve Assembly
LOCATION OF SERVICE:
%d �
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f
( c� �roiil ��.'
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The baci�Iow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vain•**+ Breaker
^T Doubic Check Valve � Atmosphere Vacuum Breaker
A � � f;
Manufacturer ft✓J'�G S Size
Modei Number
�i(�C� -� � Located AL t r�
Scriai Number f� S�
The above is ratified to be true.
Film Name.- Lv � �� `�- >rlc�� �7i Certified Testier
� �'J
Firm Address'fl.F� ��*- /IS�i+� = / -i 7�- '�F�����Cert. Testa No. Dau
Gauge # /�� 7/����
Date last accuracy tested �� �f - � '�
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL7UM BREAi�R
Double Cheek Valve Assembly
1st Check
2nd Cheek
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
-'Closed Tight �S
Opened at
Opined at
DSld
� -,s
Tight ' * f�
Leaked ; : ��3 �
vsid
vsid
RP- vsid
i sled p
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Aftu
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight o
vsid
vsid
RP sid
The above is ratified to be true.
Film Name.- Lv � �� `�- >rlc�� �7i Certified Testier
� �'J
Firm Address'fl.F� ��*- /IS�i+� = / -i 7�- '�F�����Cert. Testa No. Dau
Gauge # /�� 7/����
Date last accuracy tested �� �f - � '�
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy