2014_1010 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT'
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NAME OF PWS: CITY OF COPPE�
PWS I.D. #
LOCATION OF SERVICE: �� � r I u� C___��
The bacl�low preveation asscmbly detaile� below has baa tested aad maintain� � nq�� bv TNRCC
r�gularions aad is certified to be operating within acceptable parameters.
TYPE OF ASSENlBLY
e Reduced Pressure Principle e Pressure Vacuimm Breaker
� : '�.. Dauble Che�c Valvc �_ ' G . Atmosphero Vacuum Breaker
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Maaufacttaer �r��, Siu �
ModeiIvumber {��_�`� LocatedAt 1 Z.�\ ��c�,n��
Serial Nimmba �:-_3':: f C.��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Tight � Opcned at Opeaed at esid
Tight �l Leal:ed ❑ �sid osid
�,S R.P- Z��Dsid t �-I
�� ❑ Did not Opea o Leal:ed o
�P�
and
, . Mataials �
�� U� R�' �,
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Test ARer DC-Closed Closod Tight o Opened at Opeaed at __osid
Repair Tight ❑ csid �osid
R.P sid
The above is catified to be true.
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Firm Name 1't x� Catified T
s � m ��
Firm Addrre,uu � ' '�5 Cert. Teste No. Z Date �_f�"
,
c�suge # f���t�2�(��
llate last accuracy tested _ �•7 (- ��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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