2012_1025CIIECK ONE:
IRRIGATION
DOMESTIC
FIR ELLN E
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D_ #
CITY OF COPPELL
LOCATION OF SERVICE: ''�:i �O� %/� -C'�> �" --ftJ C G�
The baci�low prevmtioa assembly detailed below has bees tested aad maintained as required by TNRCC
rc2ulatiotLS and is certified to be opQating within acceptable parameters_
C Reduced Pressure Principle
�� _ Double Check Valve
0
Maaufact�ser ��t7"» f ��
Model Number c%
Serial Number � � Q ��
TYPE OF ASSEMBLY
C Pressurc Vactnmm Breaker
� Atmosphere Vacuum Breaker
e-
SiZC
Located At C �"��- �"�'�1 r�
The above is certified to be true.
Firm Name �- L-�� / L ,�/ �/� Certified Teste -_ f�»"r" f - pc�s�s-�*�
Firm Address � t � �� �/f- ��.u5+�%�� Cert. Tests No. 7/.� �� Date .� �� S /�-
Gauge # ,+i� � /�S
Date last accuracy tested �� �6 -�/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRE_�►T�R
Double Cher3c Valve Assembly
1st Chec3c
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed r � f
Tight �� � d
Closed Tight
Leaked �
Opined at
vsid
Opined at
nsid
nsid
RP- nsid
Leaked o
Did not Opea o
Leaked '�
�P�s
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight �
nsid
vsid
RP sid
The above is certified to be true.
Firm Name �- L-�� / L ,�/ �/� Certified Teste -_ f�»"r" f - pc�s�s-�*�
Firm Address � t � �� �/f- ��.u5+�%�� Cert. Tests No. 7/.� �� Date .� �� S /�-
Gauge # ,+i� � /�S
Date last accuracy tested �� �6 -�/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy