2012_0730CHECK ONE.
IRRIGATION DOMESTIC FIRELIN E
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPE'LL
PWS I.D. #
LOCATION OF SERVICE: 3 � fO � '� � �' � � s�-+ � k �-'� '
The baci�low prcvmtioa assembly detailed beiow has bem tested and maintained as mquurd by TNRCC
rcgulations and is certified to be opQating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Prznctple C Pressttrc Va�-+n++*+ Breaker
,2t: Doubic Chcck Valve C Atmosphere Vacuum Breaker
r � !/
Manufacaser 1 '.-' � Size
Model Number - Located At »Y
Serial Number � ' : : -r `�' �
The above is certified to be true.
Firm Name � i-( Liu L �� ?�_ Certtified Tester - � .
Firm Address % 3 3 S �LC � G S ✓L�i Cent Tester No. `" - � '' � � Date %� -'' `�� '
�` /��,- FYI v � n . �X 7Sc� Z Z
Gauge # O 309' o �/ b Z-
Date I$st accuracy tested 4 -' / % - ZO � Z-
White - Customer's Copy Yellow -City Copy Pink - Tester *s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT�R
Double Check Valve Assembly
1st Cheek
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
osid
;�i :;':< ...!
Tight [a'
Rp_ ��' . /osid
Leaked a
Leaked �
; _
asid
osid
Did not Opm o
Leaked �
Rcpatrs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight �
vsid
osid
RP sid
The above is certified to be true.
Firm Name � i-( Liu L �� ?�_ Certtified Tester - � .
Firm Address % 3 3 S �LC � G S ✓L�i Cent Tester No. `" - � '' � � Date %� -'' `�� '
�` /��,- FYI v � n . �X 7Sc� Z Z
Gauge # O 309' o �/ b Z-
Date I$st accuracy tested 4 -' / % - ZO � Z-
White - Customer's Copy Yellow -City Copy Pink - Tester *s Copy