2012_0322CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELIN
BACICFZOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS: CITY OF COPYELL
PWS I.D. #
LOCATION OF SERVICE: r.
The bacl�low prcvmtion assembly detailed below has bem tested and mair�ra;ned as required by TNRCC
regulations and is certified to be operating within acceptable parmmetcrs_
TYPE OF ASSEMBLY
C Rcduccd Pressure Principle C Pressure Vacuimm Breaker
�. Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At -
Serial Number
The above is certified to be true.
Firm Name � i
Firm Address
Gauge #
Date Iast accuracy tested
Certified Testa
Cent. Tester No. - Dan
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJ'CJM BIZ�AI�R
Double Check Valve Assembly
1st Check
tad C'hecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Ti�bt :g.
Leaked G7
nsid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked o
Rcpaus
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight O
Opined at
Opened at
nsid
Repair
Tight [7
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � i
Firm Address
Gauge #
Date Iast accuracy tested
Certified Testa
Cent. Tester No. - Dan
White - Customer's Copy Yellow -City Copy Pink - Testers Copy