2011_0718CIIECK ONE.
IRRIGATION
DOMESTIC
�'
FIRELINE V
BACT�Z.OW PREVENTION ASSEA�LY TEST AND MAIIVT'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �U � �N��S � \-� ��-
The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulatiotLS and is ccrti.£ed to be operating within acccptablc paramctrrs_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressurc Vacuum Breaker
n Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
j /r '
i - .l -�.
tzc
Located At
- ;r_ -��;_ rc,;r �r_�ry��
The above is certified to be true.
�_;� .
Firm Name �� � � �; %�; � " t_. y "- T(= A�< < Certified Tests � � - �: �. r� � ,
Firm Address ?C�c>� � CerL Testa No �` ; =� �� `\ Date � ' `� i �
� .c c�3
Gauge # L
llate last accuracy tested � { \ fj
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheel:
tad Chccl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opined at
Opened at
nsid
Tight
Leaked O
nsid
nsid
�
R.P- �- nsid
_, ,
�
F�
Lcak� o
�
Did nos Open o
Leaked �
�P�s
and
Materials
used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
�_;� .
Firm Name �� � � �; %�; � " t_. y "- T(= A�< < Certified Tests � � - �: �. r� � ,
Firm Address ?C�c>� � CerL Testa No �` ; =� �� `\ Date � ' `� i �
� .c c�3
Gauge # L
llate last accuracy tested � { \ fj
White - Customer's Copy Yellow -City Copy Pink - Testers Copy