2012_1010 (4)CIIECK ONE:
IRRIGATION_ DOMESTIC
FIREI,INE
BACKFI.OW PREVENTION ASSEA�LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacl�low prevention assembly detailed below has been tested aad n,a;.,ra;,,cd as required by TNRCC
reeulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle a Pressure Vacutmm Breaker
`� Double Check Valve o Atmosphere Vacuum Breaker
Manufacnaer /= �' �� �% Size
.� �i
Model Number � � S � Located At / � `� " � � }/� � �_¢
Serial Number � �'? � �
The above is certified to be true.
Firm Name �� �� d LL- % / � � Certified Tester /°'f /� r L'�� /�� /� S
Firm Addc+ess / = //�'�j� Y 7� 7 �� y� T `Geri. Tester No. 13�C�G�lJ07C1 Dau !C% - -1 G' ��
Gauge # 1, /y U Y � 7y�
Date last accuracy tested —
�% /i� /L-
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI�LBLY
PRESSURE VACUUM BRE_AT�R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Checl.
Closed Tight T�
I -caked / � �
Opened at
vsid
Opmcd at
vsid
vsid
Initial Test
DC- Closed
Tiahi /" '� '�
Rp- vsid
Lcal:ed O
Did aoc Opm o
Lcai:ed �
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opened at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name �� �� d LL- % / � � Certified Tester /°'f /� r L'�� /�� /� S
Firm Addc+ess / = //�'�j� Y 7� 7 �� y� T `Geri. Tester No. 13�C�G�lJ07C1 Dau !C% - -1 G' ��
Gauge # 1, /y U Y � 7y�
Date last accuracy tested —
�% /i� /L-
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy