2014_1010 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINB
BACI�'i.OW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPORT
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NAME OF PWS: CITY OF COPPE�L
PWS I.D. #
LOCATION OF SERVICE: �'S � C��,..�YJ C��c�
The bacl�low preveation assembly detailed beiow has beea tested aad m��nt�ed as required by TNRCC
regulations aad is cerdfied to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacu�Breaker �,
i _ ,�t Double Chcok Valve_ �; ., 4 Amiosphere Vacuum Brealcer
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Maaufactiaer �-1.�5 Siu (��
Model Number <`�7C��'� � Located At ��"?2`=� ���c-��,, � �
SerialN�ber C�"a��t--,
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Doubk Cbeck v alve Assembly
lst Check 2nd Cbecl: Relief Valve Air Inlet Checic Valve
Inival Test DGClosed Closed Ti�t 7a Opeaed at Opcned at _osid
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Tight � Leal:ed o nsid _osid
� � � R.P. 1 � ;�� sid
I,�;� o } y Dia noc Opea o Leai;ed a
�P�
and
Mataials
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� ;�: Used � ,
Test ARer DC-Closed Closed Tight o Opened at Opmed at _T sid
Repair Tight ❑ �sid �sid
RP sid
The above is certifie�to be t�ve.
Fum Name
Catifiod T a.
i��l.%`'� l.r*� ���i� i��,
Firm Address th1�,�A1�`h�1�; � . �X �5��� Cert.Testc Na Date 1°��-►4
Gauge # ��11€1��to�i �
llate last accuracy tested � - 2_ �- ��-�
W"te - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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