2012_1025CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCR REPORT
NAME OF PWS:
PWS I_D. #
CITY OF COPPELL
LOCATION OF SERVICE: /[7 5 � �iL�-- L-- �l� -l�Y -rte./ rE3
The bacl�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
C Reduced Pressure Principle
Double Check Valve
Maaufacittrer �yf� S
Model Number �- %��'�
Serial Number % � 6 � �
TYPE OF ASSEMBLY
C PteSSUrC Var�m+ BieakCr
❑ Atmosphere Vacuum Breaker
Size
Located At '- ' -X =..
The above is certified to be true.
Firm Name L.✓ � fr i�-� 'f �r�tl� ��F-1 Certified Tester . ; , =
Firm Address �Q� 1-^ � 'f ' '/ �"�'"�r'� Cert. Tester No. Date �_ -
Gauge # ; /�? 7th; �-,
Date last accuracy tested ���/(�- ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRE_AT�R
Doubie Cherlc Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed-
Tiabt L7
Closed Tight D
Leaked ❑
Opened at
nsid
Opened at
nsid
vsid
RP- nsid
I �ai�i a
Did not Opea o
Leaked ❑
�Pm�
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opined at
vsid
nsid
RP std
The above is certified to be true.
Firm Name L.✓ � fr i�-� 'f �r�tl� ��F-1 Certified Tester . ; , =
Firm Address �Q� 1-^ � 'f ' '/ �"�'"�r'� Cert. Tester No. Date �_ -
Gauge # ; /�? 7th; �-,
Date last accuracy tested ���/(�- ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy