2012_1026CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAIiVZ'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: S � � � h � a
The bacidlow prcvmtion assembly detailed below has bem tested and maintained as required by TNRCC
reeulaaons aad is certified to be operating within acceptable parameters_
C Reduced Pressure Principle
� Double Check Valve
1'
Maaufactsaer ��'^:�'�'Y�P �`
Model Number . -C` jT -�T`7/ �7
Serial Number / Si ��
TYPE OF ASSEMBLY
c Pressure Vacuinn Breaks
o Atmosphere Vacuum Breaker
Size
Located AL � �-+ �
The above is certified to be true.
Firm Name � � � . - -. - --
Fitm Address /���[+'�� /� � -'`
Gauge # /� �� � S
Date last accuracy tested !/- �(j -�/
Certified Tester
Cert. Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY
PRESSURE VACiJLIM BRFAKFIZ
Double Check Valve Assembly
1st Check
2nd Checi:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed �
Closed Tight �
Opined at
Opined at
nsid
Ti_eht �
Leaked o
nsid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked '.�
�P�s
sad
Materials
Used
Test Afia
DC- Closed
Closed Tight a
Opined at
Opined at
osid
Repair
Tight 0
nsid
osid
RP sid
The above is certified to be true.
Firm Name � � � . - -. - --
Fitm Address /���[+'�� /� � -'`
Gauge # /� �� � S
Date last accuracy tested !/- �(j -�/
Certified Tester
Cert. Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy