2012_1025CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE �� ----
BACKFZOW PREVENTION ASSEMBLY TEST AND MAIPiTENANCE REPORT
NAME OF PWS.
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �f7 /C> �,c �p.vrG l
The bacicflow prevention assembly derailed below has been tested and maintained as required by TNRCC
regularions and is terrified to be operating within acceptable parameras_
c Reduced Pressure Principle
� " Double Check Valve
Manufactaffer ,�7�Y4o
Model Number �� � �
Serial Number �i �S E7'�f
TYPE OF ASSEMBLY
e Pressure Vacurnn Breaker
o Atmosphere Vacuum Breaker
�r
Size �
Located At t �".37.�- 1`�C =�- �p
The above is certified to be true.
Firm Name � rr.Ii. i / f` ✓ _ >rr�t/ ?'4-7 Certified Testa �: %� ��f s�'_c -✓� %S ,' � .d .,-
Firm Address `r'�� T��l6,�rP>/ i��1� CeR. Tester No. Date '> � �� --
3
Gauge # � �' i �� %%. S-' -' ('?
Date Iast accuracy tested �� �6 �l
White - Customer's Copy YeIIow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI.TiJM BRF'A�'R
Double Check Valve Assembly
1st Cheek
2nd Cheek
Relief Valve
:fir Islet
Check Valve
Initial Test
DC- Closed _ j4'� r- �
_Closed Tight R' �
Opened at
Opined at
vsid
Tight
Leaked �� o
vsid
vsid
RP- nsid
��� p
Did not Open o
Leaked '-�
Rcparrs
and
Materials
Used
Test After
Repair
DC- Closed
Tight a
Closed Tight o
Opined at
vsid
Opened at
nsid
nsid
RP std
The above is certified to be true.
Firm Name � rr.Ii. i / f` ✓ _ >rr�t/ ?'4-7 Certified Testa �: %� ��f s�'_c -✓� %S ,' � .d .,-
Firm Address `r'�� T��l6,�rP>/ i��1� CeR. Tester No. Date '> � �� --
3
Gauge # � �' i �� %%. S-' -' ('?
Date Iast accuracy tested �� �6 �l
White - Customer's Copy YeIIow -City Copy Pink - Testers Copy