2012_1025CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEirIBLY TEST AND MATNI'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �C. -�0�� '�✓�n0- �.y�9tit�F'
The bacicflow prevention assembly detaiied beiow has bees tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
C Reduced Pressure Priaciplc
�* � Double Check Valve
Manufacturer
Modei Number r �(�JOCS'
Serial Number 11��a�
TYPE OF ASSEMBLY
e Pressure Vann**+ Breaker
o Atmosphere Vacuum Breaker
Size `/
Located At t� � > G=
The above is certified to be true.
Firm Natue - G✓� ` "?° S, °l Certified Tester - � �' � .
Firm Address �� ��^���"' __ T � - Cert. TestQ No. Date ,
s
Gauge # /�� ��� � /
Date last accuracy tested .'� �6 -� /,/�
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA�'R
Double Check Valve Assembly
1st Cheek
2nd Cheek
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Close�� L�
Closed Tight
'Opened at
Opined at
nsid
Tight
Leaked j , ��' �
nsid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked �
Rcpatrs
and
Materials
Used
Test Afirs
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Natue - G✓� ` "?° S, °l Certified Tester - � �' � .
Firm Address �� ��^���"' __ T � - Cert. TestQ No. Date ,
s
Gauge # /�� ��� � /
Date last accuracy tested .'� �6 -� /,/�
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy