2012_1025CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE }�
BACKFi.OW PREVENTION ASSEIrIBLY TEST AND MAI1V PENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: /OS SS 7�l ��Yc �P
The bacl�low prcvmtion assembly detailed below has hem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Va�-+n***+ Breaker
_T3 Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer �Y3✓`'P `'> Sizc r� ,
Model Number c�� Located AL �� ` " -`''�"
,.
Serial Number �� ��
The above is certified to be true.
i
Firm Name C.,✓ %� rP-�.� Certified Tester � �,- �- i-p-'� ,i' e�n � '?�.. -- - .r
fJ
� 1
Firm Address " c3D 7+/r�� �/1- �ay -�-u ��ert. Tester No. � "- Date ,,�. >- - � � -- .
T�
Gauge � '�?y � /8`Sh
Date last accuracy tested �`� /� - �/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFtF'�*T�'R
Double Check Valve Assembly
1st Cheri:
tad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
- Opened at
Opined at
nsid
Tight << :" � `
RP- 'nsid
Leaked. -, r-� o
nsid
vsid
Leaked o
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight a
Opened at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
i
Firm Name C.,✓ %� rP-�.� Certified Tester � �,- �- i-p-'� ,i' e�n � '?�.. -- - .r
fJ
� 1
Firm Address " c3D 7+/r�� �/1- �ay -�-u ��ert. Tester No. � "- Date ,,�. >- - � � -- .
T�
Gauge � '�?y � /8`Sh
Date last accuracy tested �`� /� - �/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy