2012_0612 (2)CHECK ONE.
IRRIGATION DOMESTIC
FIRELII�TE
BACIiF'LOW PREVENTION AS.SFPVIBLY TEST' AND CE REPORT
NAME OF PWS
CLTY OF COPPELL
PWS LD. #
LOCATION OF SERVICE: �j �Q rn m o n d
The baeldlow � assembly detailed below >� bees cest«i and mainuined as required � TNRCc
regulations and is certified to be o�peratiag withia acceptable parameters_
C Reduced Pressure Priaeiple
❑ Double Check Valve
Maw -�:�. GUa �-� S
1+,Ioael Number �? /� I
serial N�ber .�c�9 3
TYPE OF ASSEI��LY
e Presstao Vag Bseaioer
o Atmosphere Vaccnma Breaker
size
Zlr
Located At
The above is c¢'tifiod to be tare_ //
Fum Name �� -tOv� F /.�� P�� S Certi.5ed Tester ! �l1�SOvc t`-f�/ STd'�
Firm Address ��� %� 7 /.C.%CcX� �- tat�iC.Cest. Testa No_ /7�lnS� i)a�te -�I�
Gauges (J(2 / /yr� -> S
Date Iasi a���u -8�y testes
white - ct�stome>r's copy Ye11ow -city Copy P/nIc - Tester's copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAC[IUM SREAI�R
Double Ch�edc Valve Assembly
1st Cheek
2nd Check
Relief Valve
Air Inlet
Cdeeic Valve
InitiaP Test
DC- Closed
Closed Tight ❑
Opeaed at
Opened at
used
Tighs ❑
r ..9t -� ❑
used
used
Rp- used
7 r,.L,.,� ❑
Did not Opea ❑
L,eaiocd ❑
Repairs
sad
Matai�t�
Used
Test After
Repair
DC- Closed
Tighe ❑
Closed Tight ❑
Opened at
used
Opined at
osid
�sid
RP
The above is c¢'tifiod to be tare_ //
Fum Name �� -tOv� F /.�� P�� S Certi.5ed Tester ! �l1�SOvc t`-f�/ STd'�
Firm Address ��� %� 7 /.C.%CcX� �- tat�iC.Cest. Testa No_ /7�lnS� i)a�te -�I�
Gauges (J(2 / /yr� -> S
Date Iasi a���u -8�y testes
white - ct�stome>r's copy Ye11ow -city Copy P/nIc - Tester's copy