2012_1025CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKF'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I_D. # /
LOCATION OF SERVICE: �T_J � � �� Gtr ��
The bacl�low prcveation assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuimm Breaker
' �' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer � Size � +
Model Number �-/��� ^7�� Located At C� ���� /%
Serial Number �o.-� �
The above is certified to be true.
Firm Name `! � . %• �- -�'� /— Certified Teste
Firm Address �'�� ���•�/ ������� Cert. Tester No. ���(�� Date�� "� ��-
"�7�
Gauge # l( -� %�� S
Dat¢ last accuracy tested ��- �� - ��
Whit¢ - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR�'AT�'R
Double Check Valve Assembly
1st Checl:
2nd ChecI:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight C7
Closed Tight O
Leaked'`; o
Opeaed at
osid
Opened at
osid
vsid
r
RP- � vsid
�� p
Did not Open O
Leaked �
�Pa;'
and
Materials
Used
Test Afars
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
vsid
Opened at
vsid
vsid
RP sad
The above is certified to be true.
Firm Name `! � . %• �- -�'� /— Certified Teste
Firm Address �'�� ���•�/ ������� Cert. Tester No. ���(�� Date�� "� ��-
"�7�
Gauge # l( -� %�� S
Dat¢ last accuracy tested ��- �� - ��
Whit¢ - Customer's Copy Yellow -City Copy Pink - Tester's Copy