2012_1026CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE ''
BACKFT.OW PREVENTYON ASSEA�LY TEST AND MAINTENANCE REPORT
NAME of Pws:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ��/� ��.�t/��iy� �� -P
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable paramctas_
TYPE OF ASSEMBLY
C Reduced Pressure Principle c Pressure Vacutmz Breaker
-� Double Check Valve � Atmosphere Vacuum Breaker
rf
Maaufacttaer ��-n -U `� Size
Model Number ��f�G%ti!� Located AL - � %,����°
Serial Number rrfi�
The above is certified to be true.
Firm
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V?�CLTUM BRF�iE�R
Double Check Valve Assembly
Certified Testa -_
/' `�
_�"�'"�
Firm
1st Cheri:
tad Checl:
,/
/�����
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed !`r �
Tight a"
_Closed Tight ®'
Leaked o
"Opined at
nsid
Opined at
nsid
nsid
RP- nsid
-
Leaked p
Did not Opm o
Leaked �
Repairs
and
Mata-ials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm
Name "�, �`%✓
f.l ,��
Certified Testa -_
/' `�
_�"�'"�
Firm
Address x%4'.3
- fs�F�fii�.�'i.�,
,/
/�����
"� Cert. Tester No.
� l� �
Date /�J ",=��'
,
Gauge # �caa %/ o s�
Date last accuracy tested ��- :�G ��
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy