2012_1026CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF Pws: CITY OF COPPE'LL
PWS I_D. #
LOCATION OF SERVICE: � U l -�
=-
The bacicflow prevention assembly detailed below has been tested and ,nai„rai*+ed as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle c Pressure Va�-uL+**+ Breaker
_^_ Double Check Valve D Atmosphere Vacuum Breaker
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Maaufacturcr � � :'+-a r-F
Model I�+umber l � t'Y`it�fi ��,
Serial Number 1 �i^ 1 ��
Size
Located AL
The above is certified to be true.
Firm Name _> . (� %�� , r -� - -
Firm Address � �r %� T''
Certified Tester
Cert. Tester No. Date
Gauge # �nr� �/� S tv
Date Iast accuracy tested �� ��j - ��
White - Customer's Copy Ye11ow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFt>?.e.rrFR
Double Check Valve Assembly
1st Check
2nd Cbecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight r3'
Opened at
Opined at
nsid
Tight o�
Leaked o
nsid
nsid
RP- nsid
��� p
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Aftu
DC- Closed
Closed Tight o
Opined aL
Opined at
nsid
Repair
Tight a
z'sid
nsid
RP sid
The above is certified to be true.
Firm Name _> . (� %�� , r -� - -
Firm Address � �r %� T''
Certified Tester
Cert. Tester No. Date
Gauge # �nr� �/� S tv
Date Iast accuracy tested �� ��j - ��
White - Customer's Copy Ye11ow -City Copy Pink - Tester's Copy