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2014_1010 C�IECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPE�� PWS I.D. # LOCATION OF SERVICE: �S 3 C_.\��D C.a� The bacldlow prcveation asscmbly detaile� below has beea tested aad maintain� � nq�� bv TNRCC re�sulations aad is certified to be operating within acceptablc paramcters. TYPE OF ASSEMBLY C Reduced Pressvre Principle � Pressure Vacu�Breaker _ �_ Double Che�k Valve �- . p Amiosphere Vacuum Breaker �`" : -__ - . � _ , _. . � �� Maaufact�er n�f S Siu ` Model Ivumber �G't�t�'f� Located At 1(�`�21 �r��n�n�e� Scrial N�ber C7lc�f>r\ REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R ' Double Check Valve Assembly lst Check 2nd Chec1: Relief Valve Air Inlet Checic Valve Inidal Test DGClosed Closed Tight � Opened at Opened at �osid Tight �! Leal:ed o _nsid __esid �y��5 RP- 2��1 nsid , ,� "r Leal:ed o Did not Opea o Leal:e� � RePairs aad ; Mataials �.�_. U� � ��; • � � � �� `� Test After DC-Closed Closed Tight o pp��az (�peaed at �sid Repair Tight o _�sid __osid RP sid The above is certified to be true. f' Firm Name,�eE�,w.��b(1�I� ��f k '1`c c� Certified T ; r�� h} �rY��sc Sa : FitmAddresslt��G.xahc�rl�.,�,, ,�� 'f�1�P -s"j Cert. TesterNo.��I��Date �C�-/(^�/�J Gauge # �tI 1R-12�l�� llate last accuracy tested �• �� White- Customer's Copy Yellow - City Copy Pink-TesteNs Copy _ _ _ _ . _ _ __ _ _ ,�