2012_0509CHECK ONE:
IRRIGATION_ DOMESTIC_ FYRELIAIE
BACT{FI.ORy PREVENTI ®tV ASSEIrIBLY iEST AIVD 1�iA.IIVTENiANCE REPORT
NAME OF PWS. CITY OF C(�PPL'LL
PWS I_D. #
LOCATION OF SERVICE: US Postal Service, 951 W. Bethel Road
The bacicflow prevention asscmbly detailcd bclow has bccn trsted and ma;.,ra +**. -Ya as rcquired by TNRCC
rc_eularions and is ccrtified to be operating within acccptable parameters_
TYPE OF ASSEMBLY
0 iZeduced Pressure Principle c Pressure Vacuc� Brcakcr
0✓ Doublc Chcck Valvc O Atmosphere Vacuum Brc�iK
Manufacascr Hersey Size 4"
Model l�iumber �C: Locatod At Riser #4
Serial Number not legible
The about is certificd to be true.
Fran Namc Professional Backflow
Firm Addtsss 5068 Avery, The Colony
Gauge # 372461
Date last accuracy tested 03/03/12
Cettified Tester Scott Masdon �-
Cert. Toter No. 2524 Date 05/09/12
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE
ASSEA�ffiLY
'PRESSURE VACUUM Bi'L s�'R
Double Cbec3c :%give Assembly
Ist Chec3c
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closcd Tight �✓
Opmcd at
Opmcd at
vsid
Ti� 2 0✓
Leal:cd �
vsid
vsid
RP- vsid
2.0
'�
��� Q
Did not Opm Q
Lcaked
Rcpaus
and
Materials
used
Test Aiicr
DC- Closed
CIosed "iip�ht o
Opmcd at
Opmcd at
vsid
Repair
Tiv,�tt t7
Mid
vsid
)iP sid
The about is certificd to be true.
Fran Namc Professional Backflow
Firm Addtsss 5068 Avery, The Colony
Gauge # 372461
Date last accuracy tested 03/03/12
Cettified Tester Scott Masdon �-
Cert. Toter No. 2524 Date 05/09/12
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy