2012_0601 (4)BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPF.LL
PWS I.D. #
LOCATION OF SERVICE: G
The baclflow prevention assembly detailed below has been 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 Vacuum Breaker
Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer / 7�T s Size
Model Number 7 / Located At %el
Serial Number 3� �' l3 / A m "S A- G
The above is certified to be true. �� �i /
Firm Name ACIA9 Al // P Certified Tester 1'111 // e zz11 11- S
Firm Address ��! �� 1/ 7 Cat. Testa No. �,��Od Date
Gauge # Oi!� e ylll'
Date last accuracy tested y �` 2
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ,.W-
Closed Tight `,Ri
Leaked r �% C
Opened at
nSid
Opened at
-pSid
osid
RP- ,_„psid
Leaked o
Did not Open o
Leafed C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_nsid
Repair
Tight C
osid
nsid
RP std
The above is certified to be true. �� �i /
Firm Name ACIA9 Al // P Certified Tester 1'111 // e zz11 11- S
Firm Address ��! �� 1/ 7 Cat. Testa No. �,��Od Date
Gauge # Oi!� e ylll'
Date last accuracy tested y �` 2
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy