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2014_1230_RPZ (4) C�iECK ONE: �� IRR.IGATION DOMESTIC FIftELINE • BACI�LOW PREVENTION ASSEMBLY TEST AND M�INTENANCE REPORT' � ;.� � � �� . . �� . . CITY t�F COP�,ELL ;.;� � `. ` � ; rr;��oF;Pws: , j. : :: _ . , , _ , , .. k � � , , . . ,. � . . . �: � . . Pws I.D.#� , � '� , ,: j} � 1_: LOCATION OF SERVICE: �u�° � �C� .S �1 e' , c� :; � The bacl�low preveation assembly detaile� below has beea tested and maintained as required by TNRCC r�cguladons and is cerdfied to bc operating within acr.tptablc paramcters. TYPE OF ASSEMBLY � Rcduced Pressurc Principle ❑ Pressure Vacui�Breaker ^_ Double Check Valve o Atmosphere Vacuum Brea�er Manufact�uer ,' C S� y�L-' Modei Ivumber ��'d � Located At � '"` f` � Scrial Nimmber �7 3 � �° `� �!'� ��`�` REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assembly ist Check 2nd Chec�: Relief Valve �1ir Inlet Check Valve Inival Test DGClosed Closed TiQ t at ed at osid Ti�t � Leal:cd � �sid _osid RP-�sid �r � � L,�;� ❑ Did not Opea o Leal:e� � RePairs and Mataials Used Test After DGClosed Closed Tight o Opened at Opmed at nsid Repair Tight o �sid osid RP sid The above is cerdfied to be true. jj �/ � � (S Firm Name f�/���� l���t�-3'Lt�' Certified Testa ���n �( Firm Address� ��� �� � � � Cert. Tester Na '� Date ���` Y�������r�������� Gauge # tYJ���(��� llate last accuracy tested ��-�-- � White - Customer's Copy Yellow - City Copy Pink-Tester's Copy