2012_1030CIIECK ONE -
IRRIGATION�� DOMESTIC
FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �� � � • �'oPP�'LL
The bacicflow prevention 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 Rcduccd Pressure Principle C Pressure Vacutmm Brraks
Double Check Valve � Atmosphere Vacuum Breaker
> 3 "'
Manufacturer /� //q�Ts _ Size /��' -!
ModeiNumber -7�/� � LocatcdAt (� �%� %fle N� �/✓. CD/e/�%��
Serial Numbs sG S 8 3
The above is certified to be true. ]� �p p � � �
Firm Name �nIK �4�K,< -CIx�� ��a�S Certified Tester '�JOpA,�/_itll E L-�/ 7
Firm Address ®�� � �l i��tCLE�T�2fBCert. Tester No. SOB$ �3 Date �O 3 2 - /Z
Gauge # O��oo9�5'
Date last accuracy tested � Jz -/ Z.
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B�FA�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Test
�S�RP-
DC- Closed,.
Tight ��
nsid
�� p
Closed Tight
Leaked � o
��
Opined at
nsid
Opined at
nsid
Did not Opm o
nsid
Leaked �
Repairs
and
Materials
Used
Test Alts
Repair
DC- Closed
Tight �
Closed Tight v
Opined at
nsid
Opined at
nsid
nsid
RP sid
The above is certified to be true. ]� �p p � � �
Firm Name �nIK �4�K,< -CIx�� ��a�S Certified Tester '�JOpA,�/_itll E L-�/ 7
Firm Address ®�� � �l i��tCLE�T�2fBCert. Tester No. SOB$ �3 Date �O 3 2 - /Z
Gauge # O��oo9�5'
Date last accuracy tested � Jz -/ Z.
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy