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2012_1010 (5)
CIIECK ONE. IRRIGATION DOMESTIC FIRELINE BACT�T.OW PREVENTION ASSEMBLY TEST AND MAIl�i'I'ENANCE REPORT NAME OF PwS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: A S S C� e e �m M The bacl�low prevention assembly detailed below has been tested and **+a +*+ a **+ed as required by TNRCC rcQUlations aad is certified to be operating within acceptable parameters. C Reduced Pressure Principle PRESSURE VACUUM BR>:'arr�'R Double Check Valve Double Check Valve Assembly ' �' � 5 2 �� Manufactrn-er / Model Nrnnber � C�/2 1st Checl: Serial Number �% G% � In �' j� Air Inlet TYPE OF ASSEMBLY c Pressure VacuL�*n Brcaktr � Atmosphere Vacuum Breaker �r Size Located At � ��' �O �lz P `"� �'' `' /� The above is cer'tificd to be true. Firm Name ��' �� a �'`- /� / � f Firm Addmss � � • 7 y 7 lfi /'¢ Y�1- T� Gauge # ©G o �/ / 7 � � Date last accuracy tested �� -� � - �� Certified Tester � //� � � / / //% /� s Cert. Tester No. /��rl0 m o �o� Date /U -!O • loZ White - Customer's Copy Yellow -City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BR>:'arr�'R Double Check Valve Assembly 1st Checl: ?ad Checl: Relief Valve Air Inlet Check Valve Initial Test DC- Closed ''?- �� Tight Closed Tight � Leaked j � � Opeaed at nsid Opined at nsid nsid RP- nsid �� p Did not Opm o Leaked � Reparts and Materials Used Test ARu Repair DC- Closed Tight � Closed Tight o Opined at nsid Opeaed at nsid nsid RP sid The above is cer'tificd to be true. Firm Name ��' �� a �'`- /� / � f Firm Addmss � � • 7 y 7 lfi /'¢ Y�1- T� Gauge # ©G o �/ / 7 � � Date last accuracy tested �� -� � - �� Certified Tester � //� � � / / //% /� s Cert. Tester No. /��rl0 m o �o� Date /U -!O • loZ White - Customer's Copy Yellow -City Copy Pink - Tester's Copy