2012_0828 (4)CHECK ONE.
IRRIGATION
DOMESTIC
FIREI.INE
BACKFI.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �'LL� -� ��"'��� /�- �-- � �
�"�.S
9 ����I�J'
I
The bacicflow prevention assembly derailed below has been tested
aad ma;nrained
as r'etjrrired
by TNRCC
regulations and is certified to be operating within acceptable parameters_
Check Valve
1st Check /. �
2nd Cheek /. �
TYPE OF ASSEMBLY
e Reduc. -d Pressure Principle a Pressure Vacurmm Breaker
�� Double Check Valve � Amt /m /osphere Vacuum Breaker
Manufacturer �- -��'��O Size ! �T /
Model Number �� �' T Located At l� '--��t S� �D _ ✓ ..a'�`��
Serial Number � 3" �' `�
The above is certified to be true.
Firm Name Q c�a- -- �+�0 Pyv-5 CeRified Tester �1�+ �. �G��`- �'°�^ -'�
Firm Address S��% � ��= � 17 �^J�^-j Cert. Tester No. � p � � � �S�ate �- Z g� } z -
Gauge # � 7� � �' S� -�'cP
Date last accuracy tested �/�" ? �' r �—
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLT[JM BREAI�R
Double Chec3c Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check /. �
2nd Cheek /. �
Initial Test
DC- Closed
TiahL �1'.
Closed Tight
Leaked o
Opined at
nsid
Opened at
nsid
nsid
RP- nsid
��� p
Did not Open o
Leaked t7
�Pait�
and
Materials
Used
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
nsid
Opined at
nsid
nsid
RP std
The above is certified to be true.
Firm Name Q c�a- -- �+�0 Pyv-5 CeRified Tester �1�+ �. �G��`- �'°�^ -'�
Firm Address S��% � ��= � 17 �^J�^-j Cert. Tester No. � p � � � �S�ate �- Z g� } z -
Gauge # � 7� � �' S� -�'cP
Date last accuracy tested �/�" ? �' r �—
White - Customer's Copy Yellow -City Copy Pink - Testers Copy