2012_0316 (3)CIIECK ONE:
LRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSE1vIBLY 'PEST AND MAINTENANCE REPORT
NAME OF Pws: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: .U� A //L � / hQ _ �� .
The bacl: flow prevention assembly detailed beiow has been tested and maintained as requi:zd by TNRCC
rceulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
r+ Double Check Valve o Atmosphere Vacuum Breaker
Manufaciiser ' ''. , ." Size ��
i
Model Number -� 'f Located At r � � �� .� i��..f � ( /'L L V c:,. � %
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_Ar�'R
Double Check Valve Assembly
1st Checl:
tad Cheek
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Tight 0
Closed Tight [�
Leaked D
Opened at
vsid
Opined at
nsid
nsid
RP- nsid
��� p
Did not Opm o
Leaked �
Rcpaus
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
nsid
Opined at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy