2012_1026CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE t- ____
BACKF'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��� —( C _ { �-f -t_a
The bacicflow prcvmtion assembly detailed below has bees testLd and =na;nra;ned as rcquitv-d by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vaculmz Breaker
- .� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer ��.- �7'7'lO `� Size
Model Numbs n lC��
Serial Number > > � �=
Located At '- 3':'�� ��-��
The above is certified to be ttve. j
Firm Name _ <:" -� _ Cerdfia3 Teste - � «'l�i�S �"` i •���-L - -• --7_
Firm Address °' Cart Testa No. � �1��� Date /� �� /�---
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFATtFR
Double Cher3c Valve Assembly
1st Cheel:
tad Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Ti_QhL e"
Closed Tight a
Leaked � o
Opined at
vsid
Opined at
osid
vsid
RP- vsid
�� p
f " '
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Alter
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
vsid
Opined at
osid
osid
RP sid
The above is certified to be ttve. j
Firm Name _ <:" -� _ Cerdfia3 Teste - � «'l�i�S �"` i •���-L - -• --7_
Firm Address °' Cart Testa No. � �1��� Date /� �� /�---
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy