2012_0117 (2)CIIECK ONE.
IRRIGATION
b 4.b,. .. _4...:M T.
DOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY 'PEST AND MAIN'T'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: /o DU .�. %/%/�G �� / /7�f�
The bacicflow prevention assembly detailed below has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pmsurc Principle C Pressure VacuL�**+ Breaker
�' Double Check Valve D Atmosphere Vacuum Breaker
Maaufacitzrer � Size
Modei Number Located At _
Serial Number
The above is certified to be true.
Firm Name
Firm Addrrss
Gauge # r
Date last accuracy tested
Certified Tester _
Cert. Tester No.,-_
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI.TLJM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relie {Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opened at
Opined at
nsid
Tight o
Leaked o
nsid
nsid
RP- nsid
I,eal:ed p
Did not Opm o
Leaked �
Repairs
and
Materials
LJscd
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opened at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Addrrss
Gauge # r
Date last accuracy tested
Certified Tester _
Cert. Tester No.,-_
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy