2012_1025CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE - - - --
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: "���= lt-'�y � -+-ec/ c {�
The bacicflow prevention assembly detailed below has bees tested and maintained as required by TNRCC
rc_suiazions sad is certified to be operating withia acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuum Breaker
-E3 Double Check VaIvc � Atmosphere Vacuum Breaks
Manufacturer ,�'`P' `� Size
Modei Ivmnber �`� �'�� Located At , ' ,' -� ` �' � � -.:
Serial Number � � � � �
The above is certified to be true.
Firm Name j rc Li �i � Certified Tester
Firm Address ,:.rye � ����GCert. Tester No. Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFZF' A►T�'R
Double Check Valve Assembly
1st Cheek
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight r3 ""
Leaked a
Opened at
nsid
Opined at
nsid
nsid
R.P- nsid
�� p
Did not Open O
Leaked �
Repaus
and
Mate=-ials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight v
Opined at
nsid
Opined at
nsid
nsid
RP std
The above is certified to be true.
Firm Name j rc Li �i � Certified Tester
Firm Address ,:.rye � ����GCert. Tester No. Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy