2012_0525 (8)CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFi.OW PREVENTION ASSEirIBLY TEST AND MAII�i'I'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD_ #
LOCATION OF SERVICE: /!j/'`� f /�i"���i/ ��� ��g'' �ir� // i� �G /f
The bacicflow prcvmtion assembly detailed below has bees ttsted and maintained as requiuzd by TNRCC
regulatiotLS and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
c Rcduccd Pressure Principle °C Pressure Vacutmm Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Maaufacttn-er
Model Number
Serial Number
Size
Located At ., `'
The above is certified to be true.
Film Name l k /- Certifiod Tester
/� <.
Fitm Address - L /�.�i� - � J`� Ccrt Tester No. Dau ,
Gauge # : _`- �/���9��
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1rIBLY
PRESSURE VACWM BRF�*T�R
Double Cheek Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
_ -' vsid
Tight �
Leaked o
vsid
vsid
RP- vsid
T rai;cd p
Did not Opm o
Leaked �
RePaIR
and
Mata-iais
Used
Test After
DC- Closed
Closed Tight v
Opened at
Opined at
vsid
Repair
Tight �
vsid
vsid
RP std
The above is certified to be true.
Film Name l k /- Certifiod Tester
/� <.
Fitm Address - L /�.�i� - � J`� Ccrt Tester No. Dau ,
Gauge # : _`- �/���9��
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy