2012_1025CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFT�OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
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PWS I_D. #
CITY OF COPPELL
LOCATION OF SERVICE: r� S 3 ;.._. �_ .,` , r-r ,,t, _V.��, �,
The bacidlow prevention assembly detailed below has been testae and maintained as required by TNRCC
regulations and is certified to be opQating within acceptable parameters_
TYPE OF ASSEMBLY
c Reduced Pressure Principle c Pressure Va�-tt� Breaker
�^. Double Check Valve � Atmosphere Vacuum Breaker
_,•
Maaufactttrcr ��'j'+ -� `> Size /�`
Model Number - �i�9"�� Located At l_JT✓C -���>
Serial Number � 5 � �
The above is certified to be true.
Firm Name � - (i�_� F!�— Certified Tester /i_rifJ'r/'�> s��ll� = it -��- -�
Firm Address " �'>�% -�'l�s �i� � /`���'� 'Cert. TestQ No. ` ->� O � Dau /d - 1�� "/ �i_
-T�
Gauge # /Ci n % 1 ���
Date lest accuracy tested /� - �� - ��
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRFasrF'R
Double Chec3c Valve Assembly
1st Checl:
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed �'�
Closed Tight 'jam
Opened at
Opened at
nsid
Tight �7
RP- nsid
Leaked ;', �;,' �
nsid
nsid
Leaked o
Did not Opm o
Leaked '�
�P�s
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tighe O
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � - (i�_� F!�— Certified Tester /i_rifJ'r/'�> s��ll� = it -��- -�
Firm Address " �'>�% -�'l�s �i� � /`���'� 'Cert. TestQ No. ` ->� O � Dau /d - 1�� "/ �i_
-T�
Gauge # /Ci n % 1 ���
Date lest accuracy tested /� - �� - ��
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy