2012_1026CIIECK ONE.
IRRIGATION DOMESTIC FIRELLNE "-t-"
BACi�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # // /
LOCATION OF SERVICE: �--� �U L � � er-�F-�
The bacl�low prevmtioa assembly detailed below has been tested and maintained as required by TNRCC
regulations and is ceztified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Var+n�**+ Breaker
-�^- " Double Check Valve C Atmosphere Vacuum Breaker
,�
Manufacrtaer S Size �'
Model Number - %(� -{�Z Located At '- �� �= = r --�
Serial Number P � � 7 '1
The above is certified to be true.
Firm Name -'� � �--E -" /� Certified Testes - � : _
Firm Address 'tK� Ty��Yi � �l �i+t��Cert. Tester No. �G� (S �3 Date " - / � l ..
Gauge � �(7() %/ [�J b
Date last accuracy tested �, . ! � - f�
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRRaTrFR
Double Check Valve Assembly
1st Check
2nd Cheki:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed ;
Closed Tight
Opened at
Opined at
vsid
Tight [�''
Leaka3 _ ', C
vsid
osid
RP- vsid
it
Leaked o
Did not Opm o
Leaked C
Repairs
and
Matezials
Used
Test ASrs
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tight �
vsid
vsid
RP sid
The above is certified to be true.
Firm Name -'� � �--E -" /� Certified Testes - � : _
Firm Address 'tK� Ty��Yi � �l �i+t��Cert. Tester No. �G� (S �3 Date " - / � l ..
Gauge � �(7() %/ [�J b
Date last accuracy tested �, . ! � - f�
White - Customer's Copy Yellow -City Copy Pink - Testers Copy