2012_1012 (2)CIIECK ONE: /
IRRIGATION �✓ DOMESTIC FIRELINE
BACKF'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: %��� ��Cl�e��...�
The bacldlow prevention assembly derailed below has been tested sad maintained as requitzd by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacur•**+ Breaker
�� Double Cfheck Valve a Atmosphere Vacuum Breaker
Manufacturer ��/ Size Z ,�
Model Number nIJr1Yk i �� Located At �/�� ;.6 ��1 �"'
Serial Number �' �) �P
The above is certified to be true.
Firm Nattte �(` .�-� --�� � r r.r Certified Testa �P H � �� �— b*�� "��
Firm Addrzss `P� g � i� 7 97 lc� � Cert. Tester No.g P�d� b �S -7 Date / e� - rz- J z
Gauge # y 7� � >'o � �8
Date last accuracy tested 7 3 1 -)
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Cheek Valve Assembly
Relief Valve
Air Islet
Check Valve
1st Cheek f . �
tad Chekl: /, ,�
Initial Test
DC- Closed
Closed Tight
Opined at
Opened at
nsid
TishL
Leaked [7
nsid
nsid
RP- nsid
Leaked p
Did not Open o
Leaked �
�P�
and
Mata-ials
Used
Test Agar
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Rapair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Nattte �(` .�-� --�� � r r.r Certified Testa �P H � �� �— b*�� "��
Firm Addrzss `P� g � i� 7 97 lc� � Cert. Tester No.g P�d� b �S -7 Date / e� - rz- J z
Gauge # y 7� � >'o � �8
Date last accuracy tested 7 3 1 -)
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy