2012_1127CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEA�LY TEST AND itvIAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. # 1 C� 4` -�.
LOCATION OF SERVICE: s
The baci. -flow prevmtioa assembly derailed below has bem tested and maintained as required by TNRCC
rcgulauons and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C _ -` "Reduced Pressure Principle c Pressure Vacurma Breaker
�'` Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer � � ��` U Sizc -!'( "i
Model Number `� s -� Located At � e' r• � : !�' i f e : t. _ -::�
i
Serial Nrmzber 1 � � � ��
The above is certified to be true.
Firm Name s '
Firm Address =, ` � }
' , _
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Testa
Cent. Testa No. '� Date
Yellow -City Copy
Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJ'UM BRFSSrFR
Double Cheek Valve Assembly
1st Check
tad Cheek
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight rzf
Opened at
Opmcd at
nsid
Tight
RP- � vsid
Leaked o
vsid
nsid
i �ale�i o
Did not Opm �
Leaked �
Repairs
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Rapair
Tight �
nsid
vsid
RP sid
The above is certified to be true.
Firm Name s '
Firm Address =, ` � }
' , _
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Testa
Cent. Testa No. '� Date
Yellow -City Copy
Pink - Tester's Copy