2012_0525CHECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS.
PWS I_D. #
CITY OF COPPE'LL
LOCATION OF SERVICE: rs��n 'f7sf��y4rer � C° -vo »-) � � 5� 9 � S (�ia =v f-��. �T n 1��
The bac3etlow prevention assembly detailed below has been tested and maintained as required by TNRCC
reEUiations and is certified to be operating within acceptable paramesas_
TYPE OF ASSEMBLY
e Rcduccd Pressure Principle C Pressure Vactnmm Breaker
�C Double Check Valve � Atmosphere Vacuum Breaker
Manufacitt<er ���� c� Size 3I`1 -¢-
Model Number g D S V� h Located At ..�.�t�� S �/2 �'�
Serial Number � � O �% r � � � b Y P14 S S
The above is certified to be true.
Firm Name Q- �t -F'�� n.4 t� � �o o � / /r= .� e� :� Tx Certifiod Testa M ��h �t � L �R � c is 9 ? � -'� c! �? - D r7 % �
Firm Address I�G d3 • �;. 3 � 'a � �5 1 Cent_ Tester No_ [3 Poo l o �-. a 1, Date s 1 � s 1 I a
�rrAuvl �1 t. Tjc
Gauge # A y o � � u
Date last accuracy tested S 1 � �,
wrote - customers copy Yellow -City Copy Pink - Testers copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�R
Double Cheek Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
��5�
DC- Closed
Tight t',Jl;�
RP- � ' � vsid
Leaked o
Closed Tight �
Leaked 0
Opened at
vsid
Opined at
nsid
Did not Opm o
nsid
Leaked �
�P�
and
Materials
Used
Test ARa
Repair
DC- Closed
Tight o
Closed Tip,. ht o
Opened ai
vsid
Opened at
vsid
nsid
RP sid
The above is certified to be true.
Firm Name Q- �t -F'�� n.4 t� � �o o � / /r= .� e� :� Tx Certifiod Testa M ��h �t � L �R � c is 9 ? � -'� c! �? - D r7 % �
Firm Address I�G d3 • �;. 3 � 'a � �5 1 Cent_ Tester No_ [3 Poo l o �-. a 1, Date s 1 � s 1 I a
�rrAuvl �1 t. Tjc
Gauge # A y o � � u
Date last accuracy tested S 1 � �,
wrote - customers copy Yellow -City Copy Pink - Testers copy