2012_0531Cl[ECK ONE:
IRRIGATION DOMESTIC /� FIRELINE
BACiCFI.OW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NA.IvIE of Pws: CITY OF C'OPPE'LL
PWS I.D. #
LOCATION OF SERVICE: �G O (� 13� f 1 � `
The bac;},-flow prevention assmlbly detailed below has been tested and maintained as requirzd by TNRCC
regulations aad is certified to be operating withia acceptable parmmeiers.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
'S� Doublc Check Valve C Atmosphere Vacuum Breaker
1 � l
Manufacturer lii�/� / �S Sizc ,�,r °�
Model Number 0 G 7g� / Located At /`� z° ��'`�
Serial Nzrmbcr � �` / l / L�
The above is ennertiEed to be true. -fin
Firm Name }7C�/ O /� f /Q � Certified Tests , /! //' � GU /�� �u S
Firm Address � (%- /3e> >c 7 Y 7 �� X /7 • Cert. Teste No. I'J PD0007GU Date �� -3/ l �—
Gauge # O' � U �� / 7 � �
Date Iast accuracy tested G% la -��
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCII'LE ASSEMBLY
PRESSURE VACUUM BI2>~'aTrF'R
Double Check Valve Assembly
Ist Check
tad ChecJc
Re[ief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tim t �
Opened at
Opened at
nsid
Tight �- t%
Leaked a- o
nsid
nsid
RP- nsid
Leaked C
Did not Open o
Leaked C
Q /�`L �G/
�, �
� c� �
lL ��
Materials
Tl P�
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is ennertiEed to be true. -fin
Firm Name }7C�/ O /� f /Q � Certified Tests , /! //' � GU /�� �u S
Firm Address � (%- /3e> >c 7 Y 7 �� X /7 • Cert. Teste No. I'J PD0007GU Date �� -3/ l �—
Gauge # O' � U �� / 7 � �
Date Iast accuracy tested G% la -��
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy