2011_1209CHECK ONE.
IRRIGATION � l' DOMESTIC FIRELIAiE
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF Pws: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE: � 7 � �� �%� �, � 14 � iU
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
rceulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Frnssttre Vacutmm Breaker
�� Double Check Valve o Atmosphere Vacuum Breaker
- ,
Manufacitaer � -GF Sizc '
Model Nimzber `-� L Loeated At
Serial Ntmlber � -' � `' - - `
The above is certified to be true.
Firm Name ��� v li /� i(LIA _ Certified Tester ,` "
Firm Address � �V 1 ��/'�� 1 �� - Cent Tester No.'. `' -' Date _ ' _
Gauge # � � ? G �" l � 12y� `-tom
Dat¢ last accuracy tested � � � t �'— ( O
Whit¢ - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUiTM BRi~'a�rr�'R
Double Check Valve Assembly
1st Check
Zad Cheek
Reiief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight `>`7
,Closed Tighe �
Leaked D
Opened at
osid
Opened at
osid
osid
RP- � -- +' sid
�- � .
��� p
Did noc Opm o
Leaked '�
�P�s
and
Materials
Used
Test Auer
Repair
DC- Closed
Tighe 0
Closed Tight o
Opined at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name ��� v li /� i(LIA _ Certified Tester ,` "
Firm Address � �V 1 ��/'�� 1 �� - Cent Tester No.'. `' -' Date _ ' _
Gauge # � � ? G �" l � 12y� `-tom
Dat¢ last accuracy tested � � � t �'— ( O
Whit¢ - Customer's Copy Yellow -City Copy Pink - Testers Copy