2012_0430CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # n
LOCATION OF SERVICE: I � �D � � I � � �"� � � `r` -�
The bacicilow pnwmtion assembly detailed below has bem tested and maintained erg required by TNRCC
rcQUlations aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle a Pressure Vacuum Breaker
Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacttrrer ,` � ' - Size -
,,-
Model Number °, ice. -�, I� Located At "` `
Serial Number ` `` `- .� � < i ! =
The above is certified to be true.
Film Name I P -�� __� , , , : -- Certified Tests ` . ,
ij
Firm Address �" � � t-��: 1\ � � n � � � "� Cent Tester No. ; Dau
-7Sl F �^ -
Gauge # � � �.- � C � �-1 �
Date last accuracy tested �'a �5 - O�Q (� --
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACi.7UM BRFAT�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Checl:
2nd Checl:
Initial Test
DC- Closed i - ��'
Closed Tight � �
Opined at
Opined at
vsid
Tight d
Lcakcd ._, �
vsid
vsid
RP- vsid
I s �`,
�� p
Did not Opm o
Leaked '�
gePa,. -�
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opened at
vsid
Repair
Tight �
vsid
vsid
Rp sid
The above is certified to be true.
Film Name I P -�� __� , , , : -- Certified Tests ` . ,
ij
Firm Address �" � � t-��: 1\ � � n � � � "� Cent Tester No. ; Dau
-7Sl F �^ -
Gauge # � � �.- � C � �-1 �
Date last accuracy tested �'a �5 - O�Q (� --
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy