2012_1214 (2)CIIECK ONE:
LRRIGATION_�
DOMESTIC
FIRELIN
BACKFI.OW PREVENTION ASSEI��LY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS
PWS I_D_ #
CITY OF COPPELL
LOCATION OF SERVICE: � -' � !� h '= � P� �
The bacl�low prevmuon assmzbly detailed below has bem tested and ma;nta;ned aS I'CquirCd by TNRCC
ztgulations and is certified to be operating within acceptable parameters_
C Reduced Prtssure Principle
Double Check Valve
/— /? �-
Maaufacttacr '
Modei Nr�ba � � .5 G-
Serial Nttmber � _ / `- S/ C /
TYPE OF ASSEMBLY
C Ptcssure Va�-uL Breaker
� Atmosphere Vacuum Breaker
Size '�
Located At �✓`�I < ''_r -'< %'�� � J / �' `� �
The above is cetified to be true.
Firm Name / � �' v ; � Certified Tester /
Firm Address I" C" f' � � ? l 7 l L s9Xv/ �'`CeR Testa No. /� � G��'oc� 7t� -� Date / � /'f /L
Gauge # UGO �// 7�1G'
Date last accuracy tested
/� l �
Wtrite - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1vIBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Check
tad Cheek
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight /- � �
Closed Tight ¢�
I -naked _�. G o
Opined at
nsid
Opined at
nsid
nsid
RP- nsid
Liked C
Did not Opm o
Leaked n
and
Materials
Used
Test Aiia
Repair
DC- Closed
Tight �
Closed Tight v
Opined at
nsid
Opined at
nsid
nsid
RP sid
The above is cetified to be true.
Firm Name / � �' v ; � Certified Tester /
Firm Address I" C" f' � � ? l 7 l L s9Xv/ �'`CeR Testa No. /� � G��'oc� 7t� -� Date / � /'f /L
Gauge # UGO �// 7�1G'
Date last accuracy tested
/� l �
Wtrite - Customer's Copy Yellow -City Copy Pink - Tester's Copy