2012_0412 (3)CIIECK ONE:
IRRIGATION
DOMESTIC _
FIRELIN
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: i � `� � �, {' S�C C�-Q
The bacicflow prevention assembly detailed below has been tasted and maintained as requirzd by TNRCC
rcgulatiorts and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C _ Reduced Presstu-e Principle C Pressure Vacutmm Breaker
�" Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer _ _ `- -- Size -- __
Model Number ; " '- ^ —� �� l`' ! Located At i � r' 1 -'� • �� � � - .
Serial Number � �"
�;
The above is certified to be true.
Firm Name � �'� 5 �• �-+ � �a c r� Ca-tified Testier
Firm Address �C - � �t (� �' Cent Tester No. . � ,Data
- ; I � s o , ��► X51 toG
Gauge # j �} � L/ L)
Date Ia_st accuracy tested �j- � ?$ - � C. � .�
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRt: AtZ'T'jt
Double Cheek Valve Assembly
1st Chen:
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed ^ � `� "'
Closed Tight d
Opined at
Opined at
nsid
Ti_ehL [�
Leaked D
nsid
nsid
RP- nsid
j „ ,
Leaked o
Did not Opm o
Leaked O
Rapaus
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
vsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � �'� 5 �• �-+ � �a c r� Ca-tified Testier
Firm Address �C - � �t (� �' Cent Tester No. . � ,Data
- ; I � s o , ��► X51 toG
Gauge # j �} � L/ L)
Date Ia_st accuracy tested �j- � ?$ - � C. � .�
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy