2012_1026CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACTCFT.OW PREVEN'T'ION ASSEMBLY TEST AND MAII�TTENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��S �v � c'_ r h tr't"� -1
The bacicflow prevention assembly detailed below has been tested aad maintained as required by TNRCC
rc_eulazions aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduc. -d Pressure Principle G Pressure Vacuimm Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Maaufacnaer �� -r12� �-
Model Number �,1 PY ��
Serial Number _, �� / ���
Size
Located At
The above is certified to be true.
Firm Name (�1J - ` " Certified Testes
...� /
Film Address ; `��/ �.7-� i� 1 T Cert. Tester No. Date �O _ � lyZ
Gauge # ,��(S � / � S
Date last accuracy tested //- �p - ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Checi:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight Q
Opined at
Opined at
nsid
Tight a
Leaked a
nsid
nsid
RP- vsid
Leaked o
Did not Opea o
Leaked �
�P�
and
Materials
Used
Test ARer
DC- Closed
Closed Tight a
Opened at
Opined at
� sid
Repair
Tight 0
nsid
vsid
RP sid
The above is certified to be true.
Firm Name (�1J - ` " Certified Testes
...� /
Film Address ; `��/ �.7-� i� 1 T Cert. Tester No. Date �O _ � lyZ
Gauge # ,��(S � / � S
Date last accuracy tested //- �p - ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy