2012_1025CHECK ONE=
IRRIGATION DOMESTIC FIRELINE -
BACKFi,OW PREVENTION ASSEMBLY TEST AND MAIN'I'ENANC� REPORT
NAME OF PWS:
PWS I.D_ #
CITY OF COPPELL
LOCATION OF SERVICE= ' + - -' � � T �� � ��
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduc.. -d Pressure Principle c Pressure Vactnmm Breaker
�`' Double /Chec_k Valve � Atmosphere Vacuum Breaker
Manufacturer .�+� S Size
Model Number �-7P7 �� � Located At <�_•'� • -'Y-� c_
�;
Scriai Number �:`, '� ��
The above is certified to be true. /f
Firm Name S: / _1_ � � .r- - S�rC /i:° /� � / /Cestifiecl Tester ` -� oCfs�S �G� - -�'1
Firm Addrzss `�� it c� ._�•w -�ur -� ea /- �1.+�`"��Sr CerG Tester No. r f�t'J �'� Date l� ��5 .'�-
Gauge # ��� � �� S�
Date Iast accuracy tested �� f� ��
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'AT�'R
Doubie Check V alve Assembly
1st Checl:
tad Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed.., _
Tight � �` �
'Closed Tight
Leaked o
Opened at
nsid
Opined at
nsid
nsid
RP- vsid
��� p
'
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
vsid
Opened at
nsid
vsid
RP sid
The above is certified to be true. /f
Firm Name S: / _1_ � � .r- - S�rC /i:° /� � / /Cestifiecl Tester ` -� oCfs�S �G� - -�'1
Firm Addrzss `�� it c� ._�•w -�ur -� ea /- �1.+�`"��Sr CerG Tester No. r f�t'J �'� Date l� ��5 .'�-
Gauge # ��� � �� S�
Date Iast accuracy tested �� f� ��
White - Customer's Copy Yellow -City Copy Pink - Testers Copy