2012_1025CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAII�TTENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE= / O�� / �-� ✓���s�Cit/�- -f�[/C �
The baci�low prevention assembly detailed below has bcm tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
C Reduced Pressure Principle
Double Check Valve
Manufacturer ��l-�'i'ir,
Model I�itzmber i�3�j
Serial Number ��/ " ,
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
D Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Film Name � (- r� i� %'c lv�
Firm Address %�s�i i+c �� �{�
r
Gauge # /(?c'i 7� �S
Date Iast $��ui -any tested �/- /6 //
Certified Tester -
Cent. Tester No_ Date
White - Customer's copy Yeuow -city copy Pink - Test¢rs copy
REDUCED PRESSURE PRITl(_'IpLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
nsid
Tight a
Leaked �
nsid
nsid
RP- nsid
��� p
Did not Opm O
Leaked '�
�P�
and
Materials
Used
Test AR,er
Repair
DC- Closed
Tight [7
Closed Tight o
Opined at
nsid
Opined at
nsid
nsid
RP sid
The above is certified to be true.
Film Name � (- r� i� %'c lv�
Firm Address %�s�i i+c �� �{�
r
Gauge # /(?c'i 7� �S
Date Iast $��ui -any tested �/- /6 //
Certified Tester -
Cent. Tester No_ Date
White - Customer's copy Yeuow -city copy Pink - Test¢rs copy