2012_1129 (4)CIIECK ONE:
IRRIGATION DOMESTIC � FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE:
The bacl�low prcvmtion assembly derailed below has bem tested and =ffa;nra;ned as requu� by TNRCC
rcgtrlations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacua**+ Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer L1.� �� � � 5 Sizc � /
Model Number � G 7 Ju / Located At �° � f e iL � � /��O �` �
Serial Nr�ber l � �/ �l S �
The above is ce:-tified to be true.
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF.asc�'R
Double Check Valve Assembly
Firm Nattte �Cfi o ti r / X C
Certified Tester
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D�/ � /' � ��;
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1st Check
tad Cbecl:
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Relief Valve
:fir Inlet
Chec3t Valve
Initial Test
DC- Closed ��
Tight i�
Closed Ti�hc �
Leaked / � ',� o
Opened at
psid
Opined at
nsid
nsid
RP- nsid
��� p
Did not Opm o
Leaked �
�Pa;'"�
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
nsid
Opined at
nsid
nsid
RP sid
The above is ce:-tified to be true.
Firm Nattte �Cfi o ti r / X C
Certified Tester
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D�/ � /' � ��;
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Firth Address / • �% /j ° >' 7 y 7 ��' � Y�
TGerL Tester No.
�/ �o O D 0 7 ��
Date % � -� 9 - /°7
Gauge # O (9 O t/ / ? � "G�
Date last accuracy tested y -�a -!�
Wtute - Customer's Copy Yellow -City Copy Pink - Testers Copy