2012_0910 (2)CILECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY 'PEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: - i 'i l' \��-' t �c �S�' ^:�'.._
e � `� i �, - �7.
The baci�low prevention assemb�y detailed below has F�een tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Va�-+��+*� Breaker
� " Double Check Valve D Atmosphere Vacuum Breaker
Maaufaettacr t 4 11C \ -Cr Size �`
Model I�iumbcr `-} W C� T- Located At 1 � � -- '. `.i'
Serial Number `—
The above is certified to be true.
Firm Name � - -� .-. Certified Tester- - - ^� ��',
Firm Address ;� 1 Cent Tester No. \ ;�„-" `--i Date ". ; v " i ,__
Gauge # ` �� � �.
Date last accuracy tested ;�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA�'R
Double Cheek Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight .... �
Closed Tight C3�
Leaked o
� Opined at
nsid
Opined at
nsid
nsid
;` >
RP- nsid
��� p
Did noc Open o
Leaked C
�Pm�
and
Materials
Used
Test After
Repair
DC- Closed
Tight [7
Closed Tight o
Opined at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � - -� .-. Certified Tester- - - ^� ��',
Firm Address ;� 1 Cent Tester No. \ ;�„-" `--i Date ". ; v " i ,__
Gauge # ` �� � �.
Date last accuracy tested ;�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy