2012_0629 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPEL'Lr,
PWS I.D. #
LOCATION OF SERVICE: e cAQ (ScW— i'i
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
Double Check Valve
JC y
�
Manufacturer o
Model Number WZ
Serial Number -Zn1,(0
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size �f'f
Located At 41 AA4 IC Q&& '7_
I' up 42CA, 1- 0w2t-V-
The above is certified to be true.
Firm Na=1Z4rW
Firm Address���i_' IC�(ic�C
Gauge # 09630 9-3 ct
Date last accuracy tested 3 - ?a- Q
Certified Testa 6ywn Vf"I k
Cat. Testa No. �� I N' q 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
E&jValve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
RP- 1- Dsid
Leaked p
e6losed Tight el
Leaked -� o
Opened at
nSid
Opened at
nSid
Did not Open o
nsid
Leaked
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight C
Closed Tight o
Opened at
DSid
Opened at
_pSid
_ nsid
RP sid
The above is certified to be true.
Firm Na=1Z4rW
Firm Address���i_' IC�(ic�C
Gauge # 09630 9-3 ct
Date last accuracy tested 3 - ?a- Q
Certified Testa 6ywn Vf"I k
Cat. Testa No. �� I N' q Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy