2012_0928 (2)CHECK ONE:
IRRIGATION
F 11� # pi - I2-1 _S747
�- DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 2--
The bacl&ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�C Reduced Pressure Principle a Pressure Vacuuran Breaker
J"- Double Check Valve C Amnosphert Vacuum Breaker
Manufactsaer Size
Model Number C» �%> Located At ,Al, W-
Serial Numnber
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAIMER
Double Check Valve Assembly
1st Cbeck /, 2nd Check !, S RpWVWve Air inlet Check Valve
Initial Test DC- Closed Closed Tight k Opened at Opened at —_t)s id
Tight d' Lea G _psid __psid
RP- __-„psid
Leaked p Did not Open o Leak-ad o
Reps
and
Materials
Used
Test Aftsr DC- Closed Closed Tight o OMW at Opened at ___-psid
Repair Tight o _.. Dsid — .°sid
RP
The above is certified to be tnu.
Firm Name Cmtifd Tester
Firm Address F0 Fz' �4 i'9 7 CaL Tester No. $ P0aa 4�,s %Dates �2 -
Gauge # 0 70104-YY
Date last accuracy tested f' - j
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy