2012_0927 (2)CIIECK ONE'. -�_
IRRIGATION DOMESTIC FIRELINE '� "
BACKF'I.OW PREVEN'T'ION ASSEN!$LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPE'LL
PWS I_D. # _
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Rcduccd Pressure Principle a Pressure Vacutnn Br�ealcer
Double Check Valve o Atmosphere Vacuum Breaks
Manufactan-s
Model Number
Serial Number
Size
Located At
The above is certified to be true_
Film Name
Firm Address
Gauge #
llate last accuracy tested
Certified Testa
Ccrt. Tests No.
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Test¢r•s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Cheek
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
TiQiti a
Closed Tight o
Leaked o
� Opened at
vsid
Opined at
nsid
nsid
RP- nsid
��� p-
Did not Opm o
Leaked �
Repairs
and
MatsiaLs
Used
Test Af%er
Repair
DC- Closed
Tight o
Closed Tight v
Opined at
nsid
Opened at
vsid
nsid
RP sid
The above is certified to be true_
Film Name
Firm Address
Gauge #
llate last accuracy tested
Certified Testa
Ccrt. Tests No.
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Test¢r•s Copy