2012_1025CHECK ONE.
IRRIGATION
DOMESTIC
FIRELLNE
BACKFI,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D- #
LOCATION OF SERVICE: < g !n •y i� � L� .
The bacl�low prcvmiion assembly derailed below has bem tested and maintained as required by TNRCC
rcgularions and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Rcduc. -d Pressure Principle c Pressure Vacvu**+ Breaker
�! Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer ' i`�% � -'° � Size .''�
Model N�mmba ' "; t-" ' f"> Located At = "-s G
Serial Number -
The above is certified to be true_
Firm Name "` - �- Certifiod Tester 'T��an /r � /„�; .�- --�
Firm Address - `� '� ���Cat. Testa No. ��,f�ss Date /�� - c��' � �-
� '7�
Gauge # 1��� %!� S
Date last accuracy tested �/ - /� -�
Wtute - Customer's Copy Yellow -City Copy Pink - Test¢r's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'A�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Ynlet
Cheek Valve
Initial Test
DC- Closed: _.
Tight tl
Closed Tight
Leaked �
Opined at
nsid
Opined at
nsid
nsid
RP- nsid
Leaked o
Did not Opm O
Leaked �
�P�s
and
Materials
Used
Test ARa
Repair
DC- Closed
Tight �
Closed Tight a
Opined at
vsid
Opined at
vsid
nsid
RP sid
The above is certified to be true_
Firm Name "` - �- Certifiod Tester 'T��an /r � /„�; .�- --�
Firm Address - `� '� ���Cat. Testa No. ��,f�ss Date /�� - c��' � �-
� '7�
Gauge # 1��� %!� S
Date last accuracy tested �/ - /� -�
Wtute - Customer's Copy Yellow -City Copy Pink - Test¢r's Copy