2012_1025CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE 4--
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �D �� �iU�t��t /oG�/C" -E�
The baci�low prevention assembly detailed below has bees tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure PrinciDlc C Pressure Va�-+n***+ Breaker
,^-. Double Check Valve C Atmosphere Vacuum Breaker
Manufactan-er ,i�. �P � Size /`
Model Narmba k, 7�� Located At
Scrim Number /(o //�
The above is certified to be true.
Firm Name � J � '` Certified Testa -J -- .t�.lS �>/� ��T
Fitm Address ~lCN� ��-.. , ° "r- w� -�l /c� ert. Testa No. �l U,� Dau �/�7-: -�5 %r-
c /
Gauge # / �{) � / p
Date last accuracy tested //- /f ��
White - Customer's Copy Yellow - Gity Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEA'LBLY
PRESSURE VACUUM BREAI:�R
Double Cher3c Valve Assembly
1st Check
?ad Checit
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed.
Closed Tight
Opened at
Opened at
nsid
Tight El�
Leaked - D
nsid
nsid
R.P- nsid
- .
i ��ted a
Did not Opea o
Leaked �
i2cpans
and
Materials
Used
Test AfTa
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � J � '` Certified Testa -J -- .t�.lS �>/� ��T
Fitm Address ~lCN� ��-.. , ° "r- w� -�l /c� ert. Testa No. �l U,� Dau �/�7-: -�5 %r-
c /
Gauge # / �{) � / p
Date last accuracy tested //- /f ��
White - Customer's Copy Yellow - Gity Copy Pink - Tester's Copy