2014_0708 CHECK ONE:
IRRIGATION DOMESTIC PIRELINE
BACIFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: Co p pe l l (Y\ Gka le. _,hc3c31 de s `}
PWS I.D. #
LOCATION OF SERVICE: k 2_ (-J3 rrzrThiek Y ( 1
The baclelow prevention assembly detailed below ` has been tested and Mairnrai* red as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
11 ''
Manufacturer ()r"t"�� Size ' /
Model Number 9 ()--f Located At A e /C/9 / .-• C e
Serial Number / 13 Z `77
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Cheek Valve Assembly
1st Check 2nd Check Relief :sly; Air Inlet sid Check Valve
1>al Test DC- Closed Closed Tight lc 3 Op eat id Opened at - osid
� � 5 Tight/ Leaked ❑ /
R Opsid �
Leaked ❑ Did not Open CI Leaked ❑
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight ❑ Opened at Opened at psid
Repair Tight a osid psid
RP psid
The above is certified to be true.
/
Firm Name l We [ I 1 _L_ _7 L Certified Tester (��,Ory:� t l Y1 ; IP
Firm Address 4-50 l / � x.- � ' L Ir" - Cert Testa No. 1 � t�v � 8 1 1
Gauge # 59700C)
Date last accuracy tested 9/511
3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy