2012_1026 (2)CIIECK ONE.
IRRIGATION DOMESTIC_ FIRELINE
BACKFZ,OW PREVENTION ASSE1rIBLY TEST A1VD MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPFLI_
PWS I_D. #
LOCATION OF SERVICE:
��� ��f
The baci�low prevention assembly detailed below has been tested and ma;ntai*3ed as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
t�
Maaufacnuer �yif � � f Sue
Model Number
O U ��i (' Located At S> S, c��c fJr f j '� Try
Serial Number G' 3 T %G
The above is certified to be true. ,�i
Firm Name /�� �i o ��- / �/� T Certified Testa /�� / � L� / /!''� -� �
Film Address � � �i'o �r 7 �% 7 ��✓� Xs�" Cent Teste No_ /j f��7G -�- Date « - �G / �
Gauge # C,GO `1 / 7l O
Date Iast accuracy tested �/ — /-� /-1
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BrtFa►sc�'R
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed G
Tight ,�
Closed Tight ,�(
Leaked / _-Z o
Opm«3 at
nsid
Opined at
nsid
nsid
RP- nsid
T �aL -cd p
Did noc Opm o
Leaked �
Rcpaus
and
Materials
Used
Test Auer
DC- Closed
Closed Tight a
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true. ,�i
Firm Name /�� �i o ��- / �/� T Certified Testa /�� / � L� / /!''� -� �
Film Address � � �i'o �r 7 �% 7 ��✓� Xs�" Cent Teste No_ /j f��7G -�- Date « - �G / �
Gauge # C,GO `1 / 7l O
Date Iast accuracy tested �/ — /-� /-1
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy