2012_1010CiiECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D- #
LOCATION OF SERVICE:
9S� /"� e � Po .c %
The baCicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
re¢ulatioz►s and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Presstac Principle C Pressttrc Vacuttm Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacttaer �� � K 5 �' �f Size � /��
Model Number � C Located At ��- /il/ � o /� "- C `2 � � `" �'�
Serial Number � � � °�
The above is certi /fled to be true.
Fitm Name �Gi�i p .-c.- ! i �z � Certified Tester �i %yf' �� � //��" �
Firm Address �G` -�3° Y %Y7 ��Y� TX Cent Testa No. ���UmO 7o-�Date �� /y /�
Gauge # DG oYi � � �
Date last accuracy tested y �1 � �
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI��LY
PRESSURE VACUUM BR�AF�R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed ��
Tight �� ' 124.
Closed Tight l�'
Leaked /�oZ �
Opened at
_osid
Opined at
osid
osid
RP- osid
�� p
Did not Opm O
Leaked �
Repatrs
and
Materials
Used
Test After
Repair
DC- Closed
Tighe 0
Closed Tight a
Opined at
osid
Opened at
osid
osid
RP sid
The above is certi /fled to be true.
Fitm Name �Gi�i p .-c.- ! i �z � Certified Tester �i %yf' �� � //��" �
Firm Address �G` -�3° Y %Y7 ��Y� TX Cent Testa No. ���UmO 7o-�Date �� /y /�
Gauge # DG oYi � � �
Date last accuracy tested y �1 � �
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy