2012_1026CIIECK ONE. `/
IRRIGATION DOMESTIC /� FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: / / � ��c � %�o r�- �
The bacicflow prevention assembly detailed below has been tested and maintained as requirzd by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacutmz Breaker
5� Double Check Valve 0 Atmosphere Vacuum Breaker
si
Maaufacv,n-er ��/g f �S Sizc �
Model Number � !> 7 �'� /
stria! Number G ; � 3 � S
Located At 5 5 i ��° � f /IL/r �ci,c
The above is �c/ertified to be true.
Firm Name //c �i Crc� / - /�` r Certified Tester �: y� /� «�� /?'�v` j
Firm Address � � //70 �/ 7 y 7 C'L� �f -,c.c� Cert. Tester No. ��Fe�cy<k.l� o� Date 1!, �? G /-2-
Gauge # UGO yf7��
Date last accuracy tested `-( _/. � -/
Wtute - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRE_A�'R
Double Cheek Valve Assembly
1st Check
2nd Cbecl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed /
Tight �
Closed Tight t�
Leaked /- `/ o
Opened at
vsid
Opined at
vsid
vsid
RP- vsid
Leaked o
Did not Opm o
Leaked �
�Pair�
and
Mata-ials
Used
Test Af%s
DC- Closed
Closed Tight a
Opined at
Opened at
vsid
Repair
Tight �
vsid
vsid
RP sid
The above is �c/ertified to be true.
Firm Name //c �i Crc� / - /�` r Certified Tester �: y� /� «�� /?'�v` j
Firm Address � � //70 �/ 7 y 7 C'L� �f -,c.c� Cert. Tester No. ��Fe�cy<k.l� o� Date 1!, �? G /-2-
Gauge # UGO yf7��
Date last accuracy tested `-( _/. � -/
Wtute - Customer's Copy Yellow -City Copy Pink - Testers Copy