2012_0612 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAQO`3.OW PREVENTION ASSE11�3LY TEST AND CE REPORT
NAME OF PWS_
PWS LD. #
CITY OF COPPELL
LOCATION OF SERVICE: � � � Q �'vl I�O/'1 -nI
The bacl - flow pirvmtioa assembly detailed below has bees ttsted aad maintained as roquazd by TNRCC
zegulatioas and is eQtif ed to be operaring withia acceptable para�eters-
TYPE OF ASSEMBLY
c Reduced Pressure Principle a Pisssurc Vacwna Brealoer
Double Cheek Valve D Atmosphere Vaciumm Brealae
A+faaufacttarr f.(JA o<-�S Sizc � �,
Model Number _Z % y D�-L�A I.ocatexi At tiI E �� � i/Gc u /-�-
Serial Number l �O2 ZL1
The above is AAc�saified to be true_ 1 / ,
Ftrm Name f+C-�' �,,.. 1= , .v r �n �. � Cadfied Tester t J4 DSO ✓t �i5 7'0 �%
Firm wddt+ess I"n �x %�/ � .L.!Ja sa._ �u��ert Tester No_ `�3Poo! tala.41 Dace "J`?�JZ
Gauge # �G f / 0� 7 S
Date last accuracy tested S
Mute - customer's copy Yellow -City copy Pialc - Tester's copy
REDI3CED PRESSURE PRINGTPLE ASSEMBLY
PRESSURE VAC[diJM BREe�a
Double ChFeic Valve Assembly
lst Cheek
.'lad Checit
Relief Valve
Air Inlet
C]seelc Valve
Initial Test
DC- Closed 2. i
Closed Tight J�
Opeaod at
Opeood at
nsid
Tight
t �s><� o
vsid
nsid
RP -_psid
®
2 �
Did trot Opm O
L.eaiced e
Repairs
and
Materials
used
Test ARtr
Repair
DC- Closed
Tight t]
Clesod Tight D
Opined at
nsid
Opeaeti at
osid
psid
RP
The above is AAc�saified to be true_ 1 / ,
Ftrm Name f+C-�' �,,.. 1= , .v r �n �. � Cadfied Tester t J4 DSO ✓t �i5 7'0 �%
Firm wddt+ess I"n �x %�/ � .L.!Ja sa._ �u��ert Tester No_ `�3Poo! tala.41 Dace "J`?�JZ
Gauge # �G f / 0� 7 S
Date last accuracy tested S
Mute - customer's copy Yellow -City copy Pialc - Tester's copy