2012_1026CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFT.OW PREVEN'T'ION ASSEMBLY 'PEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �� S._� -- L � � �iti�T�t
The bacicflow prevention assembly detailed below has bees tested and ma;nra;ned ag �Quir+ed by TNRCC
re_strlations and is certified to be operating within acceptable parameta-s.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacurzm Breaker
�^. Double Check Valve o Atmosphere Vacuum Breaker
Manufacttser Size
Model Number
Serial Number
�. r._I �.
The above is certified to be true.
Firm Name � ww• ���1 r
Firm Address /y(GiA'�cF rte-''' ' -�.
Certified Tester
Cert. Tester No. Date
Gauge # �� ����j (tea
Date last accuracy tested �/- �ln ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJLTM BR�'ATtFR
Double Cheek Valve Assembly
1st Cheek
2nd Cheek
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed-
Closed Tight t3 -
Opined at
Opined at
nsid
Tight t3`
Leaked t]
nsid
nsid
RP- nsid
Leaked o
Did not Opea o
Leaked 'J
Repairs
and
Materiais
Used
Test Ai%r
DC- Closed
Closed Tight o
Opeaed at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name � ww• ���1 r
Firm Address /y(GiA'�cF rte-''' ' -�.
Certified Tester
Cert. Tester No. Date
Gauge # �� ����j (tea
Date last accuracy tested �/- �ln ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy