2012_0927M
CIIECK' ONE.
IRRIGATION_
DOMESTIC
FIRELINE ��'
BACICFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPE'LL
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow prcvmtioa assembly detailed below has bem trstcd and maintained as requutd by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
c Reduced Pressure Principle C Pressure Vac-�n***+ Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Iv immber
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRF'ar�'R
Double Cheek Valve Assembly
1st Check
tad Checl.
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Tight __ [T"
Leaked D
nsid
nsid
RP- nsid
��;� p
Did not Opm D
Leaked �
Repairs
and
Materials
used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tigktt [7
nsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy