2012_0217CHECK ONE:
IRRIGATION 1)OMESTMC� _ FIRELINE
BACMOW PREVENfiON ASSEMBLY TEST AND MAINTENANCE REPORT
NAMvM OF PWS: CITY OF COPPELL.
PWS I.D. #
LOCATION OF SERVICE: 12-0 j (-..
The back-flow 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 Vacuum Breaker
2C Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer i.1 X14 Size
Model Number _ -774--- Located At _t►!c � l�— ��Z CfrrL �,E� c �� fir �e��i �'
Serial Number A& q&)
jE)
REDUCED PRESSURE PRINCIPLE ASSE.NMLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
�j Ist Check Znd Cbeci:
Relief Valve I.Airlalet Cheek Valve
Initial Test DC- Closed Closed Tight %C
Opened at Opened at sid
Tight Leaked Cl
osid _- --osid
RP- _,psid
Leaked o
Did not Open O Leaked
Repairs
and
Materials
Used
Test Alta DC- Closed Closed Tight o
Repair Tight
Opened at Opened at _nsid
RP sid
__-- -_ psid _ esid
The above is certified to be true.
Firm Name L C. r1 t 2x r/ � Certified Tester 4p •.' r r J� +,� �L I Chi
Finn Address e, g 2r.1 -7 Cat
Testa No. IYQUJ OL `; / Date
`
Jay
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy