2012_0510 (3)CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF Pws_ CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE§ ��� ���TH��-
The bacicflow prevention assembly detailad below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable par-mmeters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacutmm Breaker
� Doubie Check Valvo� fl Atmosphere Vacuuffi Breaker
Maaufacuaer
Modei Number
Serial Number
Size
iocated At � I � r i'-� �- t--� -�
The above is ca-tified to be true.
Firm Name a �- x`71 [> 1-� � �� Certified Tester, � � K-� L't-�� LL. % f9YVLS
Famm Addrea8' � � � � (� x i�17 , _ Ccrt_ Tester Nos �17 (x�l 7 L>rL �,� � S " /b-7 2
Gauge �* LXp ��/ ! -j �i t7
Date Last accuracy tested � � 2 ' � Z
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT�R
Doubie Cheek Valve Assembly
1st Check
tad Chccl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight G3
Closed Tight o
Leaked o
Opened at
vsid
Opened at
osid
vsid
RP- vsid
��� p
Did not Opm o
Leaked '�
RePa:. -e
and
Materials
Used
Test Aftu
Repair
DC- Closed
Tight o
Closed Tight t7
Opined at
vsid
Opened at
vsid
vsid
RP sid
The above is ca-tified to be true.
Firm Name a �- x`71 [> 1-� � �� Certified Tester, � � K-� L't-�� LL. % f9YVLS
Famm Addrea8' � � � � (� x i�17 , _ Ccrt_ Tester Nos �17 (x�l 7 L>rL �,� � S " /b-7 2
Gauge �* LXp ��/ ! -j �i t7
Date Last accuracy tested � � 2 ' � Z
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy