2011_1011CHECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS_ CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE: r`� =' �?! � `��� /�S �� Ve-
The bacicflow prcvmtion assanbly detailed beiow has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
c
�''
Manufacturer
Reduced Pressure Pzinciplc
Double Check Valve
V�/� -ifs
TYPE OF ASSEMBLY
C Pressure Vacu�nn Breaker
� Atmosphere Vacuum Breaker
size
3 /y ..
Modei Number Qa % M 3 � T Located At � /i V� 5 � � i`LP �l S � � ��L
Serial Number � � � � �
The above is ca-tified to be true.
Firm Name f'� � fJCC C /G� /!!W Certified Tester �v� ` r w� /'�
Firm Address � 3 3S %�/il'KL�/� �• Cat Tester No. �dd � Z % 2 D Dart �� � �
r�Gs' /Mdv .� -�SLzz
Ga.,ge � o3,oq v �6 Z
Date last accuracy tested '� �g - ��
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR��R
Double Cheek Valve Assembly
1st Cherlt
tad Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Te/st
DC- Closed
Closed Tight �
Opened at
Opined at
nsid
�S�O-
'Q��i� ��
Tight � "� , r'
RP- osid
Leaked �
Leaked o
�' c �'
osid
nsid
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test ARrs
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight 0
nsid
osid
RP sid
The above is ca-tified to be true.
Firm Name f'� � fJCC C /G� /!!W Certified Tester �v� ` r w� /'�
Firm Address � 3 3S %�/il'KL�/� �• Cat Tester No. �dd � Z % 2 D Dart �� � �
r�Gs' /Mdv .� -�SLzz
Ga.,ge � o3,oq v �6 Z
Date last accuracy tested '� �g - ��
White - Customer's Copy Yellow -City Copy Pink - Testers Copy