2012_1026CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE �
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPYELL
PWS I.D. #
z
LOCATION OF SERVICE:
The baci�low prcvmtion assembly detailed below has been 'tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
C Reduced Pressure Principle
�' Double Check Valve
Manufacturer � -7
Model Number �-� ��c'� -ar�
SerialNtmmber ,� �C-l�5 � 3
TYPE OF ASSEMBLY
C Pressure Vacuimm Breaker
o Atmosphere Vacuum Breaker
r
Size
Located At i� � >G✓'!_:� ��_�
The above is certified to be true.
.- --. f�
Firm Name �- �` ' Certified Testar ___J -_ . ..i
/, _
Firm Address /�i� .' ,f . t /� �' i7`� Cent Tester No. � ! �� �� Date - —
Gauge # -` 2�C7 � /�st�
Date last accuracy tested ?r� ,�� �/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFar�R
Double Check Valve Assembly
1st Check
2nd Cheek
Relief Valve
Air Inlet
Check Valve
Initial Tat
DC- Closed
Closed Tight a
Opined at
Opened at
nsid
Tight o
Leaked 0
nsid
nsid
RP- nsid
Leaked �
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Agar
DC- Closed
Closed Tight a
Opined at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
.- --. f�
Firm Name �- �` ' Certified Testar ___J -_ . ..i
/, _
Firm Address /�i� .' ,f . t /� �' i7`� Cent Tester No. � ! �� �� Date - —
Gauge # -` 2�C7 � /�st�
Date last accuracy tested ?r� ,�� �/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy