2012_1010 (2)CIIECK ONE.
IRRIGATION
DOMESTIC
FIREI.INE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE
The bacldlow prcvmtion assembly detailed below has bcm tested and ma;ntained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle C Pressure Vacuttm Breaker
�Q' Double Check Valve O Atmosphere Vacuum Breaker
Maaufactttrer �J /'� K S � t� Size
i
Model Iv umber f� � � � Located At S .GL. c' U � �- e i� 't/ --¢ �- / �
Serial Number
9`I�G6 3�
The above is certifie /d to be trot.
Firm Name �c ri G' G� % -/ /� -* Certified Tester �' �� �/ f�i� « �
Firm Address �- yCert. Tester No. Date
Gauge # � � p �/� 7 y D
Date last accuracy tested � �� -may
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V ACULJM BREAI�R
Double Check Valve Assembly
1st Check
2nd Cheek
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed �� G
TishL �
Closed Tight
Leaked �
Opined at
vsid
Opined at
vsid
vsid
RP- vsid
��� p
Did not Opm D
Leaked �
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opined at
vsid
vsid
RP std
The above is certifie /d to be trot.
Firm Name �c ri G' G� % -/ /� -* Certified Tester �' �� �/ f�i� « �
Firm Address �- yCert. Tester No. Date
Gauge # � � p �/� 7 y D
Date last accuracy tested � �� -may
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy