2012_0719CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACT�F'I.OW PREVENTION ASSEMBLY TEST AND MvAINT'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL 'i % =)L � � 4' L�7fiN/ r./ / ,: -�,G r ._1 ._ „' t. fJ uf� %�'I7
PWS LD. #
LOCATION OF SERVICE: lie /f � / /'� E= /�S�l7 � �GG� �%� T.'r 7-�' �% !
The bacicflow prevention assembly detailed below has been tested and maintained as requirzd by TNRCC
rc¢ulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C � Reduced Pressure Principle C Pressure Vacurrm Breaker
�”" Double Check Valve 0 Atmosphere Vacuum Breaker
Maaufactrsrer '. - Y Size '��Y
Model Number 1 � Located At N G✓ I/A U G T - /'�IX�: L � / E'
Serial Number i � �r% t� � ,!/ � iP� c
The above is certified to be true. ` /%
Fitm Name �r � ` _ i T E R �i �' E TRO7 Cetified Tester " ' lJn�l �S� ,�-C_
Firm Address i U ? S I 4 L. Y /"l �S� A R Cert. Tester No.�%f'� O O l / 5 7 � Date % - / `� - ; .
.:_�A c L •a � Tx 7Sa?a O
Gauge # `) � / ! � '-f � ;'�.;,
Date Iast accuracy tested � - y - /��
White - Customer's Copy YeIIow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Cheri:
Initial Tat
DC- Closed
Closed Tight @'
Opened at
Opined at
nsid
Tight d
Leaked D
nsid
nsid
RP- -,', `i vsid
��
Leaked C
% , "I
Did not Opea o
Leaked C
�P�
and
Materials
Used
Test Afars
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight o
vsid
nsid
RP sad
The above is certified to be true. ` /%
Fitm Name �r � ` _ i T E R �i �' E TRO7 Cetified Tester " ' lJn�l �S� ,�-C_
Firm Address i U ? S I 4 L. Y /"l �S� A R Cert. Tester No.�%f'� O O l / 5 7 � Date % - / `� - ; .
.:_�A c L •a � Tx 7Sa?a O
Gauge # `) � / ! � '-f � ;'�.;,
Date Iast accuracy tested � - y - /��
White - Customer's Copy YeIIow -City Copy Pink - Testers Copy