2012_1025CHECK ONE-
IRRIGATION DOMESTIC FIRELINE
BACI{FI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPEI;L
PWS I.D. #
LOCATION OF SERVICE: �
The bacicflow prevention assembly derailed below has bem tested and maintained as required by TNRCC
regulations aad is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacutmm Breaker
Double Check Valve � Atmosphere Vacuum Breaks
ti
Manufacttaer .�= �/��'' ``'
Model Number �if�X� 11'7
Serial Number �:1 i`> , <;
Size
Located At
The above is certified to be true_
Firm Name S- % ff .tee_ �� � rCii 7 Certified Tester
Firm Address � � .e�/CerL Tester No. Date -
Gauge # .��lf) �i'rrs S {�
Date Iast a��ura�y testes !/- // - %/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACi.TfJM BRic'AKFR
Doable check valve Assembly
1st Cheek
?ad Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight o^'
� Opened at
Opeaed at
vsid
Tight
Leaked o
vsid
vsid
RP- vsid
T ral:� p
Did not Open o
Leaked �
�Pa„t
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
vsid
Repair
Tight 0
nsid
vsid
RP sid
The above is certified to be true_
Firm Name S- % ff .tee_ �� � rCii 7 Certified Tester
Firm Address � � .e�/CerL Tester No. Date -
Gauge # .��lf) �i'rrs S {�
Date Iast a��ura�y testes !/- // - %/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy