2012_1025CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFZ.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE: lD� S� ! �'����LC�
The baci�low prcvmtion assembly derailed below has bem tested and maintained as required by TNRCC
reeulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacurms Breaker
.�...� Double Check Valve � Atmosphere Vacuum Breaker
Manufact�aer ���Y S�2 Size ',
Model Number ' EO Z9"�Y _� Located At ��? /%Lf �
Serial Number � � �J 7
The above is certified to be ttue.
Fitm Name . ` < °` > it U/'l' x�L Certified Tester _ - - -
Firm Address ��` � T -,/'ri - . �� Y�-�+��Cert. Testa No_ Date
`_ %�
Gauge # !1?rj ��.��
Date last accuracy tested 1 �- ��, - �1
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLT[JM BRF_A�'R
Double Cheek Valve Assembly
1st Cheek
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed .:: c._ '
Tight
_Closed Tight ��
Leaked �
Opened at
nsid
Opined at
nsid
nsid
RP- nsid
Leaked p
Did not Opm a
Leaked �
R�Pair�
and
Materials
Used
Test After
Repair
DC- Closed
Tight 0
Closed Tight O
Opened at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be ttue.
Fitm Name . ` < °` > it U/'l' x�L Certified Tester _ - - -
Firm Address ��` � T -,/'ri - . �� Y�-�+��Cert. Testa No_ Date
`_ %�
Gauge # !1?rj ��.��
Date last accuracy tested 1 �- ��, - �1
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy