2012_0525 (7)CIIECK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACI{Fi,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �` r /J > / %�, r /J� ��� _ ���- // i'�- isO/
The bacl�low ptcvmtloa assembly detailed below has beta tested and maintained aS required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle f�?' Pressure Va�-+*+�**+ Breaker
Doublc Check Valvc o Atmospherc Vacuum Breaker
Manufacttaer Size
Model Number - Located At
Serial Number =:�!i ' '� "�'
The above is certified to be true.
Firm Name � >: �r �.v»a�i��'��i <y4' Ceified Teste
ski- r 1... � .�= r��-�-
Firm Address - � %� y T� � Cat Tester No. Date -
Gauge # �!'� /Q/`C'J`'�/
Date last accuracy tested � j - //
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BREAKER
Double Check Valve Assembly
1st Checl:
tad Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Ti�.ht a
Opened at
Opined at
� nsid
Tight �
Leaked o
nsid
- osid
RP- nsid
-
Leaked o
Did aot Opm D
Leaked �
Repairs
and
Matenais
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight a
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � >: �r �.v»a�i��'��i <y4' Ceified Teste
ski- r 1... � .�= r��-�-
Firm Address - � %� y T� � Cat Tester No. Date -
Gauge # �!'� /Q/`C'J`'�/
Date last accuracy tested � j - //
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy