2015_0908 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLO'W PYtEVENTION ASSEMBi.Y TEST AND MAIIV'I'ENANCE REPORT i
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rr�ME oF Pws: ELL .,
CITY OF COPP , .�
PWS I.D.# -�
1
LOCATION OF SERVICE: �''a� f�'��^I �lry �' ��'+
The bacl�low prevmtion asscmbly detailed below has beea tested aad maintained as requircd by TNRCC
regularions aad is cerdfied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Raiuced Pressure Principle � Pressure Vacu�Breaker
❑ Double Check VaIve o Amnosphere Vacuum Breaker
rp
Maaufact�er �r�' � Siu �
Model Number �f>� Locaud At /�lz t�.��°rc�rtrc'�'I fa1 s�l�'�r �� �f",�
Scrial Iv�ber l �I �1'�L1 �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Iaidal Test DGClosed Closed Ti,,P.ht Opened at Opened at nsid
Tight Leal:ed o �b psid _,osid
�i',�:3 RP-�sid �',�
L,eal;ed a Did noc Opea O Leal:ed O
RePairs
r' and
y�`�'` ' Mataials
�� Used
Test After DC-Closed Closed?ight o Opeaed at ppea�at _�sid
Repair Tight o �sid _._,osid
RP sid
The above is cerdfied to be true.
Firm Name��� . �� ✓' ' ���-- Certifiod TGster (�•t/.����..,�.,���� {r.�t..r�.,/
Firm Address �� � f,�r��j �u<� Cat Testa No.���'YY.�.��Date
Gauge # fl''��J 0 /��'�
Date last accuracy tested � -/(,~/y
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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