2012_0531CHECK ONE.
IRRIGATION
DOMESTIC �.�- ` FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPFLL
PWS I.D. #
LOCATION OF SERVICE: �S� /1� �-[ ti7`O � %�- /' r- r -
The bacicflow przvmtioa assembly detailed below has bem tested and maintained as required by TNRCC
regulations and is ceraficd to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle a Pressure Vacuimm Breaker
Double Check Valve � AtmosphQe Vacuum Breake
Manufacturer G�i�TTS Size � ' �
Model Number �`!�� � / Q% Located At ��ONr�� �� /�- � /'Ly
Serial Number
The above is certified to be true.
Firm Name � -
Firm Address �%
_,
Gauge # -
Date last accuracy tested �` - r . -: _
Certified Tester / ' - < °=�'- °_ '' - `> ._
�.
,-'
Cent. Tester No. Date - -
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUiJM BRFaKFR
Double Cher3c Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �3
Opined at
Opened at
nsid
��'< ' ' -
Tight �, �
Leaked o
n_ sid
nsid
RP- �' vsid
_ _
Lcaled a
s-
Did noc Opm o
Leaked �
RePa;,t
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � -
Firm Address �%
_,
Gauge # -
Date last accuracy tested �` - r . -: _
Certified Tester / ' - < °=�'- °_ '' - `> ._
�.
,-'
Cent. Tester No. Date - -
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy