2012_1026CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CLTY OF COPPEL L
PWS I.D. #
LOCATION OF SERVICE: _ � ��-� ` / �- �2- �`-L�!
The baci�Iow prevention assembly detailed below has been tLSted and maintained as required by TNRCC
regulations and is ceraficd to be operating withia acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle c Pressure Var+r�**+ Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacttner � �'YV��' c>
Model Number . -� (���� �
Serial Number � �X�loO
Size
Located At C �CAJ G 4�
The above is certified to be true.
Firm Name `_�- / , >� ` ` Ceraifi«i Tester
Firm Address / "Y1if/ rC r Cent Testrs No. Date -
Gauge # /���5�
Date last accuracy tested �� �� ��
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BttFau�'R
Double Check Valve Assembly
1st Check
tad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed,r
Closed Tight Fs`
Opined at
Opined at
nsid
Tight Gal
Leaked o
nsid
nsid
RP- vsid
Leaked a
Did aot Opm o
Leaked �
�P�rs
and
Materials
LTscd
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight o
nsid
vsid
RP sid
The above is certified to be true.
Firm Name `_�- / , >� ` ` Ceraifi«i Tester
Firm Address / "Y1if/ rC r Cent Testrs No. Date -
Gauge # /���5�
Date last accuracy tested �� �� ��
White - Customer's Copy Yellow -City Copy Pink - Testers Copy