2012_1025CHECK ONE:
IRRIGATION DOMESTIC FIR ELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPEGL
LOCATION OF SERVICE: /�S c� Lnh-�ec?i.._.� � _—a
The bacl�low prevention assembly detailed below has been tested and maintained ag req�rcd by TNRCC
regulations and is certified to be operating within acceptable parametats_
TYPE OF ASSEMBLY
e Reduced Presstse Principle C Pressure Vacutnn Breaker
.^� Double Chxk Valve o Atmosphere Vacuum Breaker
Maaufacttsrer ,s�- ' Size /%' '
Model Nmnber ��c�--� Located At (S'. sc=-+s o
Serial Number /. � � �
The above is cctificd to be true.
Firm Name � �/ =�� � � r
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�'R
Double Check Valve Assembly
Firm Addtrss�l�� � -�u-�� S,Cr,�
� � �
�_ /w.aJ� /,r - + Cert. Tester No.
� l �l �
Date % <J - iiS - /�_. .
1st Check
and Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed ` � ^
Closed Tight ,�
Opined at
Opined at
nsid
,
Tight 52"
RP- vsid �
Leaked - , o
€ '�
nsid
nsid
Leaked o
Did not Opm D
Leaked �
RcPait'c
and
Materials
Used
Test ARu
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight o
nsid
vsid
RP sid
The above is cctificd to be true.
Firm Name � �/ =�� � � r
- +/2_.- Certified Tester
-- %= . -n-�S,
1
s_!� ?�-�"�
Firm Addtrss�l�� � -�u-�� S,Cr,�
� � �
�_ /w.aJ� /,r - + Cert. Tester No.
� l �l �
Date % <J - iiS - /�_. .
Gauge # /(�O % ��s
Dat¢ Last accuracy tested /� l� /�
White - Customer's Copy Y¢Ilow -City Copy Pink - T¢st¢r•s Copy