2012_1010 (3)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: J�� �r -� � �Gr"
The bacll�llow prcvmtion assembly detailed below has bees tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
Double Check Valve
Manufacttser % / �K S � �/
ModelIvumber i� G
serial N�ber l � /� 3 �'
TYPE OF ASSEMBLY
� Pressure Vacua Breaker
� Atmosphere Vacuum Breaker
��Size
Located At 5 � - CG � u c �-� G- .F� �- �'L
The above is certified to be true.
�� � �i' l% ��f9/�' s
Firm Name / =mac �i � "- � _/ � T Cetified Testa
Firm Address � �- �� 1` 7 � 7 L e <f �� Cent Tester No. /3� �`�` � `J�� Date �C' �G� -/ �
Gauge # G% li d y / 7y U
Date last accuracy tested
�/ -/� /�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI.Ti.JM BRE_A►T�'R
Double Cher3c Valve Assembly
1st Chek1:
2nd Checl:
Relief Valve
:fir Inlet
Check Valve
Initial Test
DC- Clospd� �
Tight �' �
Closed Tim t �`
Leaked � o
Opened at
vsid
Opened at
osid
vsid
RP- osid
��� p
Did not Opm o
Leaked �
�Pa;''`
and
Materials
Used
Test Ai%r
Repair
DC- Closed
Tight �
Closed Tight C7
Opined at
vsid
Opined at
vsid
osid
RP sid
The above is certified to be true.
�� � �i' l% ��f9/�' s
Firm Name / =mac �i � "- � _/ � T Cetified Testa
Firm Address � �- �� 1` 7 � 7 L e <f �� Cent Tester No. /3� �`�` � `J�� Date �C' �G� -/ �
Gauge # G% li d y / 7y U
Date last accuracy tested
�/ -/� /�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy