2012_1025CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
CITY OF COPYELL
LOCATION OF SERVICE: / � � � I �.v� c� -�^ /C �
The bacl. -flow prevention assembly detailed below has bem tested and maintained as requited b�' TNItCC
rtQUlations and is certified to be operating within acceptable parametas.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Prrssurc Vacurnn Breaker
�' Double Check Valve 0 Atmosphere Vacuum Breaker
Manufactrn-er �✓3>'1..P � Size
Model Nrnnber �C'71� =3'O �1� Located At �-
Serial Number � (� /i� ��
The above is certified to be true.
Firm Name Certified Testa �'rn�' ` -' � -�� %' " ��,�-_- -�
Firm Address'` ! � Cent_ Testa No. i��l)� Date �'�
c
Gauge # %���? 7 /�S H
Date last accuracy tested �/ °�p ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL7LTM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Cheri:
Initial Test
DC- Closed
Tight G3�
Closed Tight Et'
Leaked _ D
Opened at
nsid
Opened at
nsid
nsid
RP- nsid
��� p
��
Did not Open o
Leaked �
Rapatts
and
Materials
Used
Test Altar
Repair
DC- Closed
Tight 0
Closed Tight o
Opened at
nsid
Opined at
vsid
nsid
Rp sid
The above is certified to be true.
Firm Name Certified Testa �'rn�' ` -' � -�� %' " ��,�-_- -�
Firm Address'` ! � Cent_ Testa No. i��l)� Date �'�
c
Gauge # %���? 7 /�S H
Date last accuracy tested �/ °�p ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy