2012_0412 (4)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. CITY OF COPPPLL
PWS I.D. #
LOCATION OF SERVICE: � � 3 � ` � �.. �-p 5 �; �Q
The bacicflow prevmtioa assembly detailed below has bees tested and ma;*+t �*+ed as required by TNRCC
rogttlations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Prrssurc Principle C Pressure Vacut� Breakar
Double Check Valve � Atmosphere Vacuum BreakQ
Manufacturer -t '' `�� Size -
- , � ,.
Modes Number �" t'e \ Located At ; ' ` -s _< _ f:r
Scrim Number -, � � �
The above is certified to be true.
Firm Name r � � -' Certified Tester
Firm Addrsss i ` -�C - � � � '�, Cent. Tester No. � Date -
Gauge # [ 1 C^� ?, G S �-- f �i
Date last accuracy tested 3 � � ?S - aG i �-
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B>ZF'A►T�'R
Double Cheek Valve Assembly
1st Check
2nd Cbecl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed � ^ ��
Closed Tighe ['�
Opined at
Opined at
vsid
Ti_eht d
Leaked �
asid
vsid
RP- vsid
Leaked a
! ^ 1,
Did not Opm o
Leaked �
�P�s
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
asid
Repair
Tight �
� sid
asid
RP sid
The above is certified to be true.
Firm Name r � � -' Certified Tester
Firm Addrsss i ` -�C - � � � '�, Cent. Tester No. � Date -
Gauge # [ 1 C^� ?, G S �-- f �i
Date last accuracy tested 3 � � ?S - aG i �-
White - Customer's Copy Yellow -City Copy Pink - Testers Copy