2012_0525 (12)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFT�OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � y �� S - �--� ` �c \ . �-- t � C7 �c�C�� -. i � 1 �I- /�� � � � ¢ � 5'�
The bacicflow prevention assembly detailed below has been tested and ma;n ;,,ed as required by TNRCC
rcgulatiotLS and is ca-tificd to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle L`''� Pressure Va�-uL�*n Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer �� -� -� a Sizc �.��
Model Number - � ` � E : -Y � Located At � _ � . , . - -� W a +; �
Serial Nztmber _ ,' I (:, i
The above is certified to be true.
Firm Natne _ �-
Firm Address � � `_ .
Gauge #
Date last accuracy tested �
Certified Tester ` .
Cent. Tester No. ' �, f .` + �, Date
Whit¢ — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL7'UM SRFwKFR
Double Check Valve Assembly
1st Chen:
2nd Cbeel:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
� � nsid
Tight a
Leaked o
nsid
nsid
RP- nsid
��� p
Did not Opm �
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight C7
Opened at
Opined at
nsid
Repair
Tight 0
nsid
nsid
RP sid
The above is certified to be true.
Firm Natne _ �-
Firm Address � � `_ .
Gauge #
Date last accuracy tested �
Certified Tester ` .
Cent. Tester No. ' �, f .` + �, Date
Whit¢ — Customer's Copy Yellow —City Copy Pink — Tester's Copy