2012_1026CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ��S � ��(� .%� CSI
The bacicflow prcvmtioa assembly detailed below has bem tested and maintained as required by TNRCC
regulations and is certfied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacutmm Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
3�4,.
Manufactlaer � =-E � S Size � % {
Model Number [�-7ti -� 1 Located At YPCI�"� :�i'�u�.� �� -� c7-�.-
Serial Number 4 �� ��
The above is certified to be true_
Firm Name --% t..1 • �_ i - t-''C— Certified Testa ��7'%°'s Q,,., s ���'°— �-
_/� 9
Firm Address "� tiiir � SL �/ �rrf °�+ , f /%� � Cent Tester No. �6C)� Dau `� � �6 %��
Gauge # ��l ���'S t�
Date Last accuracy tested �� —��o /�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Checi:
Reiief Valve
:fir Inlet
Check Valve
Initial Test
DC- Closed : �_ --
Tight 2T
Closed Tight a
Leaked �
��Opmed at
asid
Opined at
asid
acid
RP- asid
Leaked o
Did noc Opm o
Leaked �
Repairs
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
asid
Opined at
asid
asid
RP sid
The above is certified to be true_
Firm Name --% t..1 • �_ i - t-''C— Certified Testa ��7'%°'s Q,,., s ���'°— �-
_/� 9
Firm Address "� tiiir � SL �/ �rrf °�+ , f /%� � Cent Tester No. �6C)� Dau `� � �6 %��
Gauge # ��l ���'S t�
Date Last accuracy tested �� —��o /�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy