2012_1001 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACXFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPPLL
LOCATION OF SERVICE: /y 1 C E, S-�d
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number ;-7 M
Serial Number `� b 0 t
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At Sw 'Lev, o f f ;Q_ 0,
The above is certified to be true.
Firm Name
Firm Address ` ! 1 ,Ju
Gauge #
Date last accuracy tested
Certified Tester __
Cent. Tester No. 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
Tight ❑
Closed Tight C
Leaked C
Opened at
t)sid
Opened at
oSid
oSid
RP- Z.2 Dsid
Leaked ❑
Did not Open C
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name
Firm Address ` ! 1 ,Ju
Gauge #
Date last accuracy tested
Certified Tester __
Cent. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy