2015_1229 C�iECK ONE:
IRRIGATION_� DOMESTIC FIRELINE
Y�
BACI�LOW PREVENTION ASS£MBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPE�L
PWS I.D. #
LOCATION OF SERVICE: �7/ %"�:���-C.!'�C7 oL��l I S`��
The bacl�low prevtation assembly detailed below has beea tested aad maiatained as require� by TNRCC
regulanons and is certified to be operating within acceptable paramtters.
TYPE OF ASSEMBLY
❑, Reduced Pressure Principle e Pressure Vacui�Breaker
'�.� Double Chxk Valve � Atmosphere Vacuum Breaker
_ `.� � <<
Maaufacnaer f:;���� ��? Siu
Modei N�ber ��� E'I~ Locatcd At � � I.� °��"�`�-�'� �'`�, �,�.�—'.��
Serial Nimmber � �� ������_
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check v alv�Assembly
lst Check 2nd Checl: Relief Valve 4ir Inlet Checic Valve
Inival Test DGClosed z �-'� Closed Ti,Pht .f� Opened at Opeaed at �osid
Tisht Leal:ed � � o �sid _osid
R.P-_psid
I,eai;ed o Did not Opea o Leal;e� o
�P�
aad
Mataials
Usod _ _ __
Test After DGClosed Closed Ti,ht o ppeaed at Opme�at _�sid
Repair Tight ❑ �osid nsid
RP sid
T'he above is cerdfied to be true.
� ; �
Firm Name F' " �� °�' � ��Catifiod Testa I ��'rr.� �-- ��`�-��`�r'"
Firm Addcas��:'� �-�.�-��`-t=�'c �-�, Cat Tester No. ���'-�� Date 1 ���� - ��
(i8uge � //+�,/�r1��%�j
v
llate last accuracy tested j - �. f -�� .
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy