2013_0314 (3)CHECK ONE:
IRRIGATION
DOMESTICiX�
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPE,L
LOCATION OF SERVICE:
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer W/ f/J
Model Number cam" 0 2 A' 1
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At A -' l "L //,C, 4
AN BREAKER
Check Valve
nsid
Leaked ❑
_nsid
The above is certified to be true.
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Firm Name C/' /U �- � � �
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
Firm Addmss 7�l 7 �`�
� C Tester No.
P�r�>G6'u�'C.�- Date
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Tight /- G 9
Closed Tit
Leaked ' ' ❑
Opened at
oSid
Opened at
nSid
RP -_psid
Leaked ed ❑
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
Repair
Tight ❑
vSid
nSid
RP sid
AN BREAKER
Check Valve
nsid
Leaked ❑
_nsid
The above is certified to be true.
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Firm Name C/' /U �- � � �
Certified Tester
/J
(`j�
Firm Addmss 7�l 7 �`�
� C Tester No.
P�r�>G6'u�'C.�- Date
Gauge # aG D Y/ 7 � �
Date Last accuracy tested (/ - 1;2 -/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy