2012_1025CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE /�-
BACI�T.OW PREVENTION ASSEMBLY TEST AND MAYriTT'ENANCE REPORT
NAME OF PWS:
CITY OF COPYELL
PWS I.D. #
LOCATION OF SERVICE: -' t,_,1 � � �.i,/� c�
The bacl�low prcvmtion assembly detailed below has been tested and maintained as required by TNRCC
regtrlarions and is certified to be operating within acceptable paramctas_
TYPE OF ASSEMBLY
e Rcduccd Pressure Principle c Pressure Vacutmm Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer �"7�- -r" � Size
Modei Number .-� CJ�y +� Located At 'r'r�'z'f``�- :�1 -�`
Serial Number �_ 1 ��� _
The above is ca-tified to be true_
Firm Name fi�J - f - iZ'-- _t Src /i�i�
Firm Address' ;7i0 "�.+7t�s -file/ ���
Gauge # 1(,l� %%(f�
Date last accuracy tested /� �`j -��
Certified Tester � % � ��� : i'' ' > �- _
Cent. Tester No. ` %f' L' <� Date,'''' : �. � / ,
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'AKFR
Double Chec3c Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Islet
Cheek Valve
Ininal Test
DC- Closed Vii" �
Tight �
Closed Tight �-
Leaked O
Opined at
nsid
Opined at
nsid
nsid
RP- nsid
Leaked o
Did not Open o
Leaked �
Rrpairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight 0
nsid
nsid
RP sid
The above is ca-tified to be true_
Firm Name fi�J - f - iZ'-- _t Src /i�i�
Firm Address' ;7i0 "�.+7t�s -file/ ���
Gauge # 1(,l� %%(f�
Date last accuracy tested /� �`j -��
Certified Tester � % � ��� : i'' ' > �- _
Cent. Tester No. ` %f' L' <� Date,'''' : �. � / ,
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy