2013_1105 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
NAME OF PWS:
CITY OF COPPE, LL
PWS I.D.
LOCATION OF SERVICE: J1qYZ3 &4,C1 Rj
The backflow prevention assembly detailed below has been tested and maintained as required by TNRC
reguladons and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle 12 Pressure Vacuum Breaker
0" Double Check Valve C1 Atmosphere Vacuum Breaker
Manufacturer size
Aqe
Model Number L F 00 Located At In el ftl�� 1, ile
Serial Number QQ 2 L - -___e
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
'Ind Check-
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Closed
Tiaht a(
ld--L,k-.psid
Leaked ❑
Closed Tight te
Leaked ❑
Opened at
_psid
Opened at
________psid
Did not Open ❑
psid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC-Closed
Tight C3
Closed Tight ❑
Opened at
__—p sid
Opened at
__jsid
_ __
psid
1!,17,
RP- _.=psid_
The above is certified to be true.
Firm Nanie el tt&gj 'a(C, Certified Tester
Firm Address LLk.61UU-- �'',T Cert. Tester No. W15-1V y Date
Gauge #
Date last accuracy tested-E.2122/31-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy