2012_1025CIIECK ONE:
IRRIGATION DOMESTIC FIRELiNE �`"
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF C'OPPELL
LOCATION OF SERVICE: ,n� % �.��re7C �_ � "
The bacicflow prevention assembly detailed below has been tested and maintaiaed as requuzci by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle a Pressure Va�-v� Breaker
�.� Double Check Valve � Atmos /phere Vacuum Breaker
Maaufacnaer �j3°c° � Size
1 F ,
Model Number 7 ��'� Located At
Serial Number ��%�
The above is cerrtified to be tree. -y-
Firm Names S �� � � �/f a Certified Tester �,�,�sr' S �i��-�S
Firm Address ���� ��tfe�sr/is'� ����" Cert. Tester No. %l%� D� Dau /O �-� _ �--
Gauge # /���� %/G� -S �r�
Date last accuracy tested /� ��(p -��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAG'I7CFM BREA,I�R
Double Check Valve Assembly
1st Check
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Clo�cd
Closed Tight
Opined at
Opined at
nsid
Tight . -•' �'.- d
Leaked ,, ,--, o
nsid
nsid
RP- nsid
c:
I.ealed p
Did not Open o
Leaked �
Repairs
and
Materials
Used
Test Aftrs
DC- Closed
Closed Tight a
Opined at
Opined at
nsid
Repair
Tight �
nsid
vsid
RP sid
The above is cerrtified to be tree. -y-
Firm Names S �� � � �/f a Certified Tester �,�,�sr' S �i��-�S
Firm Address ���� ��tfe�sr/is'� ����" Cert. Tester No. %l%� D� Dau /O �-� _ �--
Gauge # /���� %/G� -S �r�
Date last accuracy tested /� ��(p -��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy