2012_1026CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACI�T.OW PREVENTION ASSE1rIBLY TEST AND rvIAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
/� ,
The bacictlow prcvmtion assembly detailed below has bem tested aad lna;.,ra;*,ed as required by TNRCC
rcgttlations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vac-tzL�*n Breaker
� Double Check Valve o Atmosphere Vacuum Breaks
Manufacttaer v.'L- sFyx�E? ��
Modei Number �h'9C9'��
Seriai Number � `> l-> t��
Size
Locat«i At
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BR>�'.e.sc�'R
Double Check Valve Assembly
1st Check 2nd Checl:
Relief Valve Air Inlet Check Valve
Initial Test DC- Closed
Closed Tight D'_
Opined at Opined at nsid
TiehL �
Leaked �
nsid nsid
RP- nsid
Leaked o
Did not Opm o Leaked 'J
Repairs
and
Materials
Used
Test Altar DC- Closed
Closed Tight o
Opined at Opined at nsid
Repair Tight O
nsid nsid
RP sid
The above is cer-tificd to be true.
Firm Name _r% G,�,, �# �_ Certified Tester
Firm Address � s 0 0 Ti/.� �.,-= �: � /t/�a,� /s< 'Geer. Tester No. Dau
Gauge # '�
Date last accuracy tested / / - -�� /�`
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy