2012_0828 (5)CIIECK ONE.
IRRIGATION DOMESTIC FIREL.INE //
BACTCFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ���. -. �� -�-c�� C�P�.G -.._ � �3S f %� _e�� --4- %��
The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Rcduc. -d Pressiu�e Principle c Pressurc VacuL***+ Breaker
Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer � -�ti Size
Model Number �" S �` Located At � w�� ���% L N.�c.PiF
Serial Number ` 3 � � t
The above is certified to be Live.
Firm
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
��'*' S
Certified Tester
�•�//�e fLe �-�°v f�2�*�'
Relief Valve
Air Inlet
Check Valve
1st Checl: /. �
2nd Cheel: !, �y
Initial Test
DC- Closed
Closed Tight �
Opened at
Opeaed at
nsid
Tight --1��
Leaked o
nsid
nsid
RP- nsid
Leaked p
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Aiiu
DC- Closed
Closed Tight o
Opened at
Opeaed at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be Live.
Firm
Name �i
t %� -�-�-
� ^�
��'*' S
Certified Tester
�•�//�e fLe �-�°v f�2�*�'
Firm
Address
1� v �3 0 �-
� 7 7
� �-^L �
Cert Tester No. R
'Pay-° /o /S � Date
� - Z � : L
gauge # 0 70 >o ��8�
Date Last accuracy tested '� - � / - 1 "�-
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy