2012_0612CHECK ONE:
IRRIGA TIO N
DOMESTIC � FIRELINE
BACKF'LOW PREVENTION ASSEA�LY TEST AND MAIN'T'ENANCE REPORT
NAME OF PwS: CITY OF C'OPPE'LL
PWS I.D. #
LOCATION OF SERVICE: ��� �� �G 'L�` t /
The bacictlow prevenrion assembly detailed below has beta tested and maintained as required by TNRCC
rcgttlations and is terrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c Reduced Pressure Princivle o Pressure Vacutmm Breaker
?�( Double Check Valve C Atmosphere jacuum Breaker
��
Manufacnaer r � �3� y Size //
Model Ntmiber `� s D Located At � � �{ T='��
Serial Number
�-/ / � /SG
Tile above is certified to be true_
Firm Name /�cf �'`� � //P �
Firm Addrrss /?l% /�rJ�r 7 � 7 G1i�9 yr.
Gauge # C>G o °%/ 7lO
Date last accuracy tested
t/ /J / �—
Cetified Testa ��i �` � �l��9� s
Cert Tester No. �3/�000C� ���Date G -�'� /1
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR><'su�'R
Double Check Valve Assembly
1st Cheri:
2nd Chect:
Relief Valve
Air Inlet
Chec3c Valve
Ininal Test
DC- Closed
Tighs �' � -�
Closed Tim t �
Leaked � O
Opened at
osid
Opened at
nsid
nsid
RP- nsid
Lcal:ed c
Ihd not Open o
Leaked �
and
Materials
Used
Test AR.er
DC- Closed
Closed Tight a
Opened at
Opened at
nsid
Repair
Tight o
nsid
osid
RP sid
Tile above is certified to be true_
Firm Name /�cf �'`� � //P �
Firm Addrrss /?l% /�rJ�r 7 � 7 G1i�9 yr.
Gauge # C>G o °%/ 7lO
Date last accuracy tested
t/ /J / �—
Cetified Testa ��i �` � �l��9� s
Cert Tester No. �3/�000C� ���Date G -�'� /1
White - Customer's Copy Yellow -City Copy Pink - Testers Copy