2012_0111CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE X
BACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: Coppe II
PWS I.D. # r _
LOCATION OF SERVICE: r N /�!' ��u f LJ�fI f 6eS
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
10C Double Check Valve
Manufacturer A r ne3
Model Number 2Gko
Serial Number VG 92a
TYPE OF ASSEMBLY
❑ Pressure Vacuun Breaker
❑ Atmosphere Vacuum Breaker
�i
Size 3 q
Located At Ri,\er RAM
The above is certified to be true.
Firm Name /411 re.
Firm Address qn E' 141cr-6n cle l/lP4w
Gauge # C4 f 0c) 9
Date last accuracy tested
Certified Tester ? G Q)
Cert. Testa No. 1 1 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 2c
Opened at
Opened at
--nsid
Tiebt -!N-
RP -jL---psid
Leaked ❑
Leaked ❑
Z"
nsid
nsid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
o sid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name /411 re.
Firm Address qn E' 141cr-6n cle l/lP4w
Gauge # C4 f 0c) 9
Date last accuracy tested
Certified Tester ? G Q)
Cert. Testa No. 1 1 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy