2012_0117CIIECK ONE:
Zl��
--
��g� -ACC �
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: L��O � /J %�-�� ��<'7h N
The bacidlow prevention assembly detailed below has been tested and maintained as requirzd by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vactm**+ Breaker
�' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Sizc / %'�_
Model I�iumbcr Located At '% / �1 : ; -
Serial Number
The above is certified to be true.
Firm Name - -%O�i� � � ; _ Certified Teste - - --
Firm Addrzss %� O`) C'f=+ �F °; 5_��.+ �� f > Cert. Testa No. ,. .. .. Date - -,
Gauge # '� ; .- l / ; -, O is
io -io —�/
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACU'IJM BRFAK'FIt
Double Check Valve Assembly
1st Chec1:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight o
Closed Tight o
Leaked o
Opined at
nsid
Opined at
nsid
nsid
RP- vsid
Leaked a
Did noc Opm D
Leaked '�
Repairs
':
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opined at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name - -%O�i� � � ; _ Certified Teste - - --
Firm Addrzss %� O`) C'f=+ �F °; 5_��.+ �� f > Cert. Testa No. ,. .. .. Date - -,
Gauge # '� ; .- l / ; -, O is
io -io —�/
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy