2012_1026CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACT�T.OW PREVENTION ASSEA�LY TEST AND MAIl�l'I'ENANCR REPORT
��`��a7�ilily
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �C7 3d vu Ce_
The baci. -flow prevention assmzbly detailed below has been tested and maintained as required by TNRCC
regulations and is cQ-tificd to be operating within acceptable parameters_
TYPE OF ASSEMBLY
c Reduced Pressure Principle C Pressure Vacut� Breaker
�, Double'C�hcck_Valvc 0 Atmosphere Vacuum Breaker
Manufacnffer ;�� Size i , '
,_
Model Number F %. Located At -' ��
Serial Number / (,-� / - �7
The above is certified to be true.
:TLJM Bi�t�t�R
Check Valve
nsid
Leaked �
nsid
Firm Name �r 1� —�-- J Certified Teste � � '• � -
Firm Address -`�� � ` �ert Tester No. Date
�- ���1�
Gauge # :' : ; "`��� `. ��
Date lest accuracy tested �� - ,°+ � %�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEl►�IBLY
PRESSURE V ACl
Double Check Valve Assembly
1st Cheek
2nd Checl:
Relief Valve
Air Inlet
Initial Test
DC- Closed "�
Closed Tight �'
Opined at
Opined at
Tight Cd'
RP- nsid
Leaked, o
,.� "�
nsid
nsid
Leaked p
Did not Opea o
Rcpaus
and
Materials
Used
Test ARer
DC- Closed
Closed Tight O
Opeaed at
Opined at
Repair
Tight �
nsid
vsid
RP sid
The above is certified to be true.
:TLJM Bi�t�t�R
Check Valve
nsid
Leaked �
nsid
Firm Name �r 1� —�-- J Certified Teste � � '• � -
Firm Address -`�� � ` �ert Tester No. Date
�- ���1�
Gauge # :' : ; "`��� `. ��
Date lest accuracy tested �� - ,°+ � %�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy