2012_0525 (9)CIIECK ONE:
IRRIGATION
DOMESTIC `� FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. #
LOCATION OF SERVICE: ���75 �� _ �-e �� \:^re \ '�
The bacic4low prcvmtion assmlbly detailed below has bcm tCStCd and maintained aS required by TNRCC
re�trlatiotrs and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Rcduccd Pressure Principle C Pressure Va�-+n�**+ Breaker
-� Double Check Valve C Atmosphere Vacuum Breaker
Manufactrn-er �: '� Sir
Model Number - - Located At �,,. -,. c, --
Serial Number
The above is certified to be true.
Firm Name ' — Certified Tester ; � � � y--
Firm Address CerL Tester No. ,, � Date
Gauge #
Date last accuracy tested
7LTM BR��R II
i
I
Chec3c Valve
nsid
Leaked C
nsid
Wlrite - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Cher3t Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight n
Opined at
Opened at
TishL o
Leaked �
vsid
nsid
��
Rp- -- vsid
��� �,
Did not Open O
RGpaIrS
�
,�%�. ka(y�
and
�Fj � �
W ^HS -�Prt
Materials
C re � �
L �� �c-
/
�7 J V �-��-
used
Test ARer
DC- Closed
Closed Tight ®
Opined at
Opined at
Repair
Tight �.
?- vsid
nsid
RP std
The above is certified to be true.
Firm Name ' — Certified Tester ; � � � y--
Firm Address CerL Tester No. ,, � Date
Gauge #
Date last accuracy tested
7LTM BR��R II
i
I
Chec3c Valve
nsid
Leaked C
nsid
Wlrite - Customer's Copy Yellow -City Copy Pink - Tester's Copy