2012_1025CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE °
BACKFI.OW PREVENTION ASSEMBLY 'PEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: '�C� -'t.�� r 0 '
The bacicflow preveatioa assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Rcduc. -d Pressure Principle a Pressure Vacui Breaker
�7`Y Double Check Valve o Atmosphere Vacuum Breaker
Maaufacturcr %:,� -u S Sizc �'�
Model Number ���7U �ss\\
Serial Number {eZ� � � V
Located AL - v "�G-
The above is certified to be true.
Firm Name � �•+/ � r - ,• / /� � � r Certified Teste = ' s �- < i = - -- _ _ -
Firm Address ��� � «sue/ >� �� �� Cent Tester No. " Dau
Gauge # l�� �i�� C
Date last accuracy tested /� -/G ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI�LBLY
PRESSURE VACWM BRE_AT�'R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Islet
Cheek Valve
Initial Test
DC- Closed
Closed Tight tom'
Opened at
Opened at
nsid
Tight d
Leaked o
nsid
nsid
RP- nsid
Lcal:ed o
Did not Opea o
Leaked �
�P�s
and
Materials
Used
Test ARu
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � �•+/ � r - ,• / /� � � r Certified Teste = ' s �- < i = - -- _ _ -
Firm Address ��� � «sue/ >� �� �� Cent Tester No. " Dau
Gauge # l�� �i�� C
Date last accuracy tested /� -/G ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy