2012_1204CIIECK ONE:
IRRIGATION
p��m.�-�cs � a a�-�
DOMESTIC
FIRELINE
BACKFi.OW PREVENTION ASSElrIBLY TEST AND MAII�TI'ENANCE REPORT'
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: I �� • L��..�' •^�•'}^ I� �Ll
The bacicflow prevention assembly detailed below has been tested aad maintained as required by TNRCC
rcgulatiorLS and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacuzmm Breaker
=+ Doubicl Ch�cc�k Valve o Atmos�p{here Vacuum Breaker
Maaufacttffer �_ �� fl 5 _ Size ✓ •• � (`
Model Number /%S � Located At �� S,-C� �v�� C�C���`r
Serial Number 1 r � t� � l�� �— � l (_/
JfJM BR��R
Cheek Valve
nsid
Leaked rJ
nsid
The above is certified to be true_ / �/
Firm Name �- iA� �, • 4 N'LTs.s`�'[`1�� Certified Tester L�C_.yit% /i/ �►S �/G L��,��5��
Firm Addr+ess� �,���1Rrri.���� f 7� Cer[. Testa No_ �/ P� / /S�G�Date __G'��
Gauge # ��7 q 1 �-
Date last accuracy tested /�? ^� /
.-
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Checl:
tad Checl:
Relief Valve
Air Idet
Initial Test
� �_�`�
DC- Closed
TighL�
LRcP -� sid o
losed Tight
Leaked o
t - .�
Opined at
nsid
Opeaed at
nsid
Did not Open o
Repairs
and
Materials
Used
Test Af�a
Repair
DC- Closed
Tight �
Closed Tight o
Opened at
nsid
Opined at
nsid
RP sid
JfJM BR��R
Cheek Valve
nsid
Leaked rJ
nsid
The above is certified to be true_ / �/
Firm Name �- iA� �, • 4 N'LTs.s`�'[`1�� Certified Tester L�C_.yit% /i/ �►S �/G L��,��5��
Firm Addr+ess� �,���1Rrri.���� f 7� Cer[. Testa No_ �/ P� / /S�G�Date __G'��
Gauge # ��7 q 1 �-
Date last accuracy tested /�? ^� /
.-
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy