2014_1010 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
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BACIQ�'LOW PREVENTION ASSEMBLY TES'T AND MAIIVTENANCE REPORT
NAME OF PWS: CITY OF COPPE,�L :
PWS I.D. #
LOCATION OF SERVICE: �'�=a C' \�,�r-� C�`:�'
The bacl�low prevmtion asscmbly detailod below has beea tested and maintained as required by TNRCC
regulazions and is cerdfied w be opera�ng within acccptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pmsure Vacu�Breaker `
� � Double Che�k Valve � � Atmosphere Vacuum Breaker
� � �
�,,
Maaufacuaer � ti��� Siu (
Model Iv umber � e�ca�3 Locaud At ��`1 C r;1 c ti,�� �
Serial Ni�ber C��(�� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubte Check v alve Assembty
lst Check 2nd Ch�cl: Relief Valve Air Inlet Checic Valve
Iainal Test DGClosed Closed Ti,,P.ht � Opened at Opened at osid
Tight � Leal:ed ❑ �sid _nsid
�` ` R.P- -`� sid
<__,
� Leal;ed ❑ � '� Did aot Opea o L,eal:ed �
�P�
aad
Matrrials
+ r Used _ ; o,,_ _ .�
Test ARer DC-Closed Closed Tight a pp�aed at Opea�at __nsid
Repair Tight o _�sid __nsid
RP sid
T'he above is cvtifiod to be true.
Firm Name e� �c . E�� Cerdfiiod T
Q'? y�J- 1"`Zc�t�.�a�r 4-_
Firm Address 1�.\�.��1��c � 1 '���ti!C`� Cert. Tester No. � ` 2 Date 10- i c- ►�I
Gauge #�el E��Z_�S(p�
llate last accuracy tested �- 7�- 1`�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy �
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