2012_0509 (7)CIIECK ONE:
IRRIGATION_ DOMESTIC I V I FIRELINE
BACI{FT.OVy PREVEN'iIOlV ASSEA�LY TEST' AND NIA.INTIEl�TANCE REPORT'
NAME OF PWS. C'l7'Y OF COPPL'LL
PWS I_D_ #
LOCATION OF SERVICE: US Postal Service, 951 W. Bethel Road
The bacl�low prcvmtiOa assClIIblV detailed below has been tCSted and mainra;n� aS rCt�ttii'ed �. TNRCC
regttlatio�ns and is cedfied to be operating within acceptable parameters_
TYPE OF ASSEMBLY
Q Retiut� Pressttre Principle a Pressure Vactrtnn $trakrr
�✓ Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer Hersey Size 4��
Model Numbs UC Locatad At Riser #2
Serial NtzIItber 8019883
REDi.ICED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V ALTnJIV1 mar a:cF7z
Double Check Valve Assembly
Ist Checlt tad Chest:
Relief Valve Air Inset Check Valve
Initial Test DC- Closed
Closed Tight �
Opmed at Opened at nsid
Tight 0✓
Leaked O
nsid nsid
6
RP- nsid
2-4
i �ai� d
Did nac Open Q Leaked o
Repairs
and
Materials
Used
Test ARrr DC- Closed
Closed Tight D
Opened aL Opmed a[ nsid
Repair Tight o
nsid nsid
RP id
The above is certified to be trot.
Firm Natoe Professional Backflow Certified Tester Scott Masdon
Firm Address 5068 Avery, The Colony Cent Tester No. 2524 Date 05/09/12
gauge # 372461
Date fast accuracy tested 03/03/12
White — Customer's Copy Yellow —City Copy pink — Tester's Copy