2012_1025CHECK ONEc
IRRIGATION
DOMESTIC
FIRELLNE
BACKFI.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: � � � � /J ti l c � Q/Z
The bacicflow prevention assembly detailed below has been tested and maintained as requu�ed by TNRCC
regularions and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Varut>� Breaker
�' Double Check Valve � Atmosphere Vacuum Breaker
�JJ f r"
ManufacLtaer /�Y-►-� 5 Size �
Model Number ��k�n � Located At ,;_,���'_ �-..,�'�-
Serial Number � c�
The above is certified to be trot.
Firm Name �' (it% �i� -/'f �rui� �i Certifiod Tester _ _ _
Firm Addrzss `✓aCi I��t-/�s;/ /�l�c*Cert Tester No_ Date
i
Gauge #
Date last accuracy tested /� /l -/�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFtF.a�R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Checl:
tad Cbccl:
Initial Tat
DC- Closed
Tight � CS'
RP- nsid
Leaked o
,Closed Tight
Leaked - C]
���
Opened at
nsid
Opined at
nsid
Did not Opm D
nsid
Leaked �
�P�s
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
nsid
Opined at
nsid
nsid
RP std
The above is certified to be trot.
Firm Name �' (it% �i� -/'f �rui� �i Certifiod Tester _ _ _
Firm Addrzss `✓aCi I��t-/�s;/ /�l�c*Cert Tester No_ Date
i
Gauge #
Date last accuracy tested /� /l -/�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy