2012_0510CHECK ONE:
IRRIGATION
DOMESTIC
FIR ELIN E
BACi�'I�OW PREVEN"I -ION ASSEMBLY TEST AND MAI1�T'I'ENANCE REPORT
NAME OF PWS:
PWS I_D. #
CITY OF COPPELL
LOCATION OF SERVICE: - —Tv � ��,� ",� -
The bacl. -IIow prcvmtion assembly detailed below has been tested and maintained as required by TNRCC
rc2ulations and is cex-tified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduces Presstirc Principle C Pressure Vacznmm Breaker
p Double Check Valve O Atmosphere Vacuum Breaks
Manufacturer
Model Number
Serial Number
Size
Located At �,' 1� �- � Z.ft-
The above is cc-ufied to be trot_
Firm Name,�,T7L�� -1 � � Cetified Testa �� r� (iC C 1NJ LL / �•s
Firm Address � D - �L,� � `Z � Cert Testa No.- ������ L� Date 5 -lG� 72
Gauge # LXpO`f ! 1 �Z
Date Iast accuracy tested � � 2 '" � Z
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
! PRESSURE VACWM BFtFaxF'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
Ist Cheri:
2nd Checl:
Initial Test
DC- Closed
Tight C7
Closed Tight o
Leaked �
Opmcd at
psid
Opined at
osid
DSld
RP- osid
Lcak� p
Did not Opm o
Lcakcd �
Repatrs
and
Materials
Used
Test Altar
Repair
DC- Closed
Tight 0
Closed Tight a
Opined at
osid
Opined at
osid
osid
RP sid
The above is cc-ufied to be trot_
Firm Name,�,T7L�� -1 � � Cetified Testa �� r� (iC C 1NJ LL / �•s
Firm Address � D - �L,� � `Z � Cert Testa No.- ������ L� Date 5 -lG� 72
Gauge # LXpO`f ! 1 �Z
Date Iast accuracy tested � � 2 '" � Z
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy