2012_0117 (6)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEA�LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
J
LOCATION OF SERVICE: /i�Ol% _J % /J /�C i��i'i i`lI/.�
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regniations and is certified to be operating within acceptable parametus_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressttrc Va�n•**� Breaker
�+ Doubic Check Valve C Atmosphere Vacuum Breaker
Maaufactaner / " �1�c. c�> Size i " --
yi
Modci Number _ � / Located At t =� ..� � ,� - <�' i
Serial Nimmber l "5 f � � `�U 7S
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent_ Testa No.
Date _
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1rIBLY
PRESSURE VACUUM BRFAT�'R
Double Cherlc Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tighe o
Opened at
Opened at
vsid
Tight o
Leaked -. - t7
vsid
vsid
RP- vsid
Leaked C
Did not Opm D
Leaked C
�P�
and
Materials
Used
Test ARa
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
vsid
Openod at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent_ Testa No.
Date _
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy