2012_0510 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFT.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacl�low prevention assembly detailed below has been tested and maintained as required by TNRCC
reeulations and is certified to be operating within acceptable parameters.
c
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
Reduced pressure Principle C Pressure Vacutrr?+ Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Size
Located At � � � %'��'C� -�- T
The above is certified to be true. nn ' '
Firm Name �� L Tt C�� 1' 1 i�-� Cetified Testa 4' l t � �=� W ! 1- L- 11Y✓✓I-
Firm Address '� - G �'�% f' -� ?� Cent_ Testa No �� �l%� � �L Date 5 �U -� 2
Gauge # C�(o�l l -1 �� (�
Date last accuracy tested � --� 2 - / `Z-
.,-
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA�R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
Ist Check
tad Checi:
Initial Test
DC- Closed
Closed Tight n
Opined at
Opined at
osid
Tight n
Leaked n
Dsid
vsid
Rp- vsid
��� p
Did not Opm n
Leaked n
Repaus
and
Materials
Used
Test Alta
DC- Closed
Closed Tight n
Opened at
Opined at
vsid
Repair
Tight 0
osid
osid
RP sid
The above is certified to be true. nn ' '
Firm Name �� L Tt C�� 1' 1 i�-� Cetified Testa 4' l t � �=� W ! 1- L- 11Y✓✓I-
Firm Address '� - G �'�% f' -� ?� Cent_ Testa No �� �l%� � �L Date 5 �U -� 2
Gauge # C�(o�l l -1 �� (�
Date last accuracy tested � --� 2 - / `Z-
.,-
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy