2012_0507CIIECK ONE:
LRRIGA TION DOMESTIC
FIRELINE
SACKFZ.OW PREVEN'T'ION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS: CITY OF COPPEI_L
PWS LD. # � � � �'1a2,1(�,�
LOCATION OF SERVICE: r 1 Z �t— �r2-�i'Z-
The baci�low prcvmtion assembly detailed below has been tested aad maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C / Reduces Pressure Pnnciplc C Pressure Vac*nn*+ Brcakar
� Double Check Valve G Atmosphere Vacuum Breaker
Maaufacturer �" � ��-U Size 3A� � �
Model Ntmnber �`S'O Located At � / (i0 ^�fQ'KE1VI (�IiL� Lny tll _C,
Seziai Number �C ?,�1.�C0 � � 1 N1riZent� � - + -��1�- (2i�� S i e1B
The above ism certified to beI true_ ^ . ,, �,' ` nr
Firma Name /W ��O (VC�� C )</iS (�.�. Certified Tesie � � ��/ ✓� V , • �I i S
Firm Address ZilO 12E[�fncL�,�T• Kc-- I(�Q.t Cent. Testa No. �P ((�_� C[ Date,- -7 - f2
T—Y- — 7cvz4p�
Gauge # O�(O'3G,S3�j
Date last accuracy tested 3 - ZO - / �
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1vIBLY
PRESSURE VACUUM BRFAirFR
Double Check Valve Assembly
1st Cheri.
tad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
osed Tight
Opined at
Opined at
nsid
Ti�ai
RP- (•� psid
Leaked q O
�
nsid
nsid
Leaked o
Did not Opm o
Leaied �
Repaus
and
Materials
Used
Test ARa
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight �
nsid
vsid
RP sid
The above ism certified to beI true_ ^ . ,, �,' ` nr
Firma Name /W ��O (VC�� C )</iS (�.�. Certified Tesie � � ��/ ✓� V , • �I i S
Firm Address ZilO 12E[�fncL�,�T• Kc-- I(�Q.t Cent. Testa No. �P ((�_� C[ Date,- -7 - f2
T—Y- — 7cvz4p�
Gauge # O�(O'3G,S3�j
Date last accuracy tested 3 - ZO - / �
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy