2014_0625 CIIECK ONE:
IRRIGATION l / DOMESTIC FIRELINE
1' S
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT r✓ ! S j
NAME OF PWS: CITY OF COPPE'LL
PWS
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and rrmainrairted as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle 0 Pressure Vac-uu + Breaker
� - � Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer li. , Size
Model Number S /� Located At ' 1 i 7 T H
Serial Number 19 L Y - � � c7a
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Cheek Valve Assembly
1st Check 2nd Check Relief Valve Air Inlet - Cheek Valve
- - - - - - - - - - - - --
Initial Test DC- Closed Closed Tight CL-- 0rrened at Opened at nsid
Tight _ Leaked a nsid nsid
RP - I vsid
Leaked Did not Open O Leaked 0
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight 0 Opened at Opened at osid
Repair Tight 0 nsid sid
RP psid
The above is certified to be true. /
Firm Name lei, q 7 Certified Tests /` / `7
Firm Address , CerL Tester No. raG 5 4 Y Date / /7--- f i l
v
-7 ) - (--) /� u
Gauge # G� Y&--2, /. y: f }
Date last accuracy tested 17., =� t
White - Customer's Copy Yellow - City Copy Pink - Testers Copy