2012_0117 (11)CIIECK ONE.
LRRIGATIO N DOMESTIC FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS_ CITY OF COPPPLL
PWS I.D_ #
LOCATION OF SERVICE_ /�OZ:i -=�- /r% /Il�NK�:/I� /ti'
The bacicflow pmmtion assembly derailed below has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacvi Breaker
�-x "" Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At _ .
The above is cerrifiod to be true.
Firm Name Certified Testa �_
Firm Address Cert. Testa No_ Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR�'AT�R
Double Check Valve Assembly
1st Check
tad Chekl:
Relief Valve
Air Ialct
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Tight o
Leake{.i o
nsid
nsid
-
RP- vsid
Lcal:ed p
Did not Opm o
Leaked �
Rcparrs
and
Materials
Used
Test Agar
Repair
DC- Closed
Tight �
Closed Tight O
Opined at
vsid
Opened at
nsid
nsid
RP sid
The above is cerrifiod to be true.
Firm Name Certified Testa �_
Firm Address Cert. Testa No_ Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy