2012_0117 (19)CIIECK ONE=
IRRIGATION DOMESTIC FIRELINE -
BACTCFI.OW PREVENTION ASSEA�LY TEST AND MAI1�iTENANCE REPORT
NAME OF PWS: CITY OF COPPE'LL
Pws I_D_ a
LOCATION OF SERVICE: l� %n J J�I�G %J,E� /ls /K
The baciflow prcvmtioa assembly detailed below has bem tasted and maintained as required by TNRCC
rcgulauons and is ccrtified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduccd Pressure Principle C Pressure Vacuimm Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer � Sizc i - - -
Model Number
Serial Nimmber
Located At c % ;� i
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested _
Certified Tester '
Cent Tester No_ � Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSE2�IBLY
PRESSURE VACUUM BREAi�R
Double Check Valve Assembly
1st Chekl:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight to
Opined at
Opmcd at
vsid
Ti_aht o
Lcaled O
vsid
vsid
RP- vsid
Lcal:ed �
_
Did not Opea o
Leaked �
Repairs
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight o
Closed Tight v
Opened at
vsid
Opined at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested _
Certified Tester '
Cent Tester No_ � Date
White — Customer's Copy Yellow —City Copy Pink — Testers Copy