2012_1025CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE - -�-
BACICFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME of Pws:
PWS I_D. #
CITY OF COPPELL
t ; � �
LOCATION OF SERVICE: ; /C /'�!�'` � / � _' '�°•� ^v �c= � ,'' ��}-
The bacicIIow prevention assembly detailed below has bcm tested and maintaiaed as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuum Breaker
.-E " Double Check Valve o Atmosphere Vacuum Breaker
� .�
Manufacturer �'�Y� -'�°5 Sizc !
Model I�iumber C=� At�-3 Located At �1`��C- �.�S - -�
Serial Nimmber �5 �� � _—
The above is certified to be true.
Firm Names `+ Certified Testa _%i l/'I1 S� �;'?� � . � -cam
Firm Add:sss � Cert Tester No. � >loDal Date LG �-�� � %�
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'AT�'R
Double Cheek Valve Assembly
1st Cheek
2nd Check
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed %r `C'
Tight
_Closed Tight #!1
Leaked �: �,� �
Opened at
vsid
Opined at
osid
vsid
RP- osid
u�;� p
Did not Open a
Leaked �
RcPairc
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opined at
vsid
vsid
RP sid
The above is certified to be true.
Firm Names `+ Certified Testa _%i l/'I1 S� �;'?� � . � -cam
Firm Add:sss � Cert Tester No. � >loDal Date LG �-�� � %�
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Testers Copy