2012_0511 (4)CHECK ONE:
IRRIGATION
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D.
LOCATION OF SERVICE: &f & a I L ,t1
The bac.Iflow 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 C Pressure Vacuuz n Breaker
5a, Double Check Valve C Atmosphere Va== Breaker
Manufacturer um 4 4 S size 2 „
Model Number
Serial Number
Located At Lo. /1 -jL:L4
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight Opened at Opened at std
Tight ;K Leaked ❑ Dsid -Psid
RP -j pi id
Leaked p Did not Open O Leaked o
Repairs
and
Materials
Used
Test After I DC- Closed Closed Tight o 1 Opened at Opened at _ sid
Repair Tight o asid Dsid
RP
The above is certified to be true.
Firm Name -lot^ Ft l2L Ace c, Certified Testa Sat., X5-7 -&/J
Frm Add: &o - "7g 7 W cyxchac� Le Cart. Tester No. /-1/0y&05,/ Date
-T�,
Gauge # (X, 116 6715
Date last accuracy tested /
White - Customer's Copy Yellow - City Copy Pink - Testees Copy