2012_1026CIIECK ONE:
IRRIGATION DOMESTIC_ FIRELINE �� .
BACKFI.OW PREVENTION ASSEMBLY TEST AND M.a►INTENANCE REPORT
NAME OF PWS.
CITY OF COPPELL
PWS I.D. # I
LOCATION OF SERVICE: �j_�ou c_-(. -twJ G�
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The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEI�fBLY
C Reduced Pressure Principle C Pressure Va�-*n*+*+ Bzeakcr
Double Check Vaivc o Atmosphere Vacuum Breaker
ri
Manufacturer �j'Y�fJ'S Size
Model Number c%�27 � Located At C YG.r �_
Serial Number � � 1 <7 �
The above is certified to be true.
Firm
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'A�R
Double Check Valve Assembly
Certified Testa , -- ` � .- � _',; ' ° _-
Firm
Address �` %r : -=✓
t� S :i :
1st Check
tad Chec3:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed '
Closed Tight �
Opened at
Opened at
vsid
Tight t7
Leaked O
vsid
vsid
RP- vsid
Leaked o
Did not Opea o
Leaked �
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
� sid
Repair
Tight o
vsid
vsid
RP sid
The above is certified to be true.
Firm
Natne � .
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Certified Testa , -- ` � .- � _',; ' ° _-
Firm
Address �` %r : -=✓
t� S :i :
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Cent Tester No_ Date --
Ga e # c
Date Iast accuracy tested
�- -,� -//
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy