2012_0117 (24)CIIECK ONE:
IRRIGATION
DOMESTIC
M.
FIREI,INE
BACTCFI.OW PREVEN'T'ION ASSE1tiIBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: JI �A�- N � �{'1 =��
The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
rc¢ulatiozss and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuttm Breaker
rzT Double Check Valve D Atmosphere Vacuum Breake
Manufacturer Size � L� -
Model Number Located At B �d , # C�
Serial Number - -
The above is certified to be true.
Fitm Name - � , "
Firm Address
Gauge � ��
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 VACUUM BFI ASR
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DGCloscd
Closed Tight �
Opened at
Opened at
nsid
TiehL !- �
L calved o
nsid
nsid
a
RP- nsid
I.eal:ed p
Did not Opca o
Leaked �
Repatrs
and
Materials
Used
Test ARer
DGClosed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight �
nsid
vsid
RP std
The above is certified to be true.
Fitm Name - � , "
Firm Address
Gauge � ��
Date last accuracy tested
Certified Tester - - —
Cert Tester No.: Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy