2012_0117 (25)CHECK ONE:
IRRIGATION
DOMESTIC
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FIRELINE
BACKFI.OW PREVENTION ASSElrIBLY 'PEST AND MAIl�1TENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. # L
t nr�e-rtn�.r n>= cF•uvTrF• l L`>� � %.���G ✓`'�/"�� / >ll.�
The bacicflow prevention assembly detailed below has been tested and maintained aS mquued by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Va�-uL�**+ Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Maaufactraer - Sizc �
-. - _.? __
Model Number - j Located At �� � <'' t
'- -
Serial Number i`' ' � ' 1 i =
The above is certified to be true.
Firm Name '� t- Certified Taus
Firm Address i /�'R' (U N� / /�., Cert. Tester No. Date
Gauge # ' >�:� lI :-, r, �.
Date last accuracy tested /(� -/b - //
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAF�R
Double Check Valve Assembly
1st Cheek
tad Checl:
Re[ief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed_ _
Tisbt �
Closed Tight D
Leaked �
Opened at
vsid
Opined at
osid
vsid
RP- vsid
Leaked p
Did not Opm o
Leaked �
RePair�
and
Materials
Used
Test Aftrs
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
vsid
Opined at
vsid
osid
RP sid
The above is certified to be true.
Firm Name '� t- Certified Taus
Firm Address i /�'R' (U N� / /�., Cert. Tester No. Date
Gauge # ' >�:� lI :-, r, �.
Date last accuracy tested /(� -/b - //
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy