2012_0911 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVEN'T`ION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS:
PWS I.D- #
CITY OF COPPELL
LOCATION OF SERVICE: :: i R� �� � CC�Y � �c i�_ � � � 1JTn 1Z =wY-\ �� Yti 1 \� \L1 rC� \ \/ L i" tiT1 ' �
The baci�low prevention assembly derailed below has been tested and maintained as required by TNRCC
rerzulataans and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuttm Breaker
�+ Double Check Valve � Atmosphere Vacuum Breaker
� ..
Manufactaffer t � `. � Size
Model Number ` <� 1 �`-\ Located At 1 �; � '� ° F- } }�
Serial Number i ' {i t ci '
The above is certified to be true.
:TUM BFt�'axFR
Check Valve
nsid
Leaked �
nsid �'
Fitm Name � � � ., � . _ '� t1� �i_ Ca-tified Tests , �' - y
Firm Address ',�' -- (')l�'�Y> � Cent Tester No_`- '\ ', - ` Date ; �:'. �� f--
Gauge # �y ���� !��}
Date last accuracy tested � Z,�Q`�1/ u
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Initial Tat
� ,,
DC- Closed
Tight __ ; ®'
RP- nsid
Leaked p
Closed Tight ®'
Leaked �
Opined at
nsid
Opined at
nsid
Did not Opm �
Rcpatrs
and
Materials
Used
Test Afirr
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
nsid
Opined at
nsid
RP sid
The above is certified to be true.
:TUM BFt�'axFR
Check Valve
nsid
Leaked �
nsid �'
Fitm Name � � � ., � . _ '� t1� �i_ Ca-tified Tests , �' - y
Firm Address ',�' -- (')l�'�Y> � Cent Tester No_`- '\ ', - ` Date ; �:'. �� f--
Gauge # �y ���� !��}
Date last accuracy tested � Z,�Q`�1/ u
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy