2014_0425 (2)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFi..OW PREVENTION ASSEMBLY TEST AND MAII�I'I'ENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
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PWS I.D. # ��1��,� ���,�
LOCATION OF SERVICE: ) �Cs(' �_ �'cJ� �L -��It� ��F
The bacicflow prevention assembly detailed below has been tested and maintain as required by TNRCC
regtiladons aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c Reduced Pressure Principle C Presstae Vacutzm Breaker
�C'�� � Double Check Valve 0 Atmosphere Vacuum Breaker
Maaufacnaer �i1 � L; Si o `�
Model Number F'.5�z Located At rJ /��� <C r/S�_J� /'z� . 7 j t`'?�- �- ��:
Serial Number �C1,3 / Z ///(1 = � . 5 .
The above is certified to be true.
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F" time ���� �� /��?" /r.�' �� Y � Certified Tests JC s c'��.c -.�� � .tz. ��rc�-
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-- -_- / f%.�.� -� Cert Tester N o�JcrysSY��t 5�/ Date � Z�S I
Firm Address r 1� - L
`?tf.C[a. !
Gauge # G +��i?�'" /f� �
Date last accuracy tested / z- - /Z --/ %3
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B RF'a►�' R
Double Check Valve Assembly
1st Check
2nd Cheek
Relief Valve
Air Inlet
Check Valve
Initial Test
(�
-Jji�s
fft
DC -Clos�
Tight
RP- i p sid
��� p
losed Tight o
Leaked �
� - . j
Opined at
n sid
Opined at
n sid
Did aoc Opm o
v sid
Leaked '�
R aP aie�
and
Mata-ials
Used
Test Agar
Repair
DC- Closed
Tight [7
Closed Tight v
Opined at
n sid
Opined at
n sid
n sid
RP sid
The above is certified to be true.
- - -T -_ //�r
F" time ���� �� /��?" /r.�' �� Y � Certified Tests JC s c'��.c -.�� � .tz. ��rc�-
�t'
\. -- - .
-- -_- / f%.�.� -� Cert Tester N o�JcrysSY��t 5�/ Date � Z�S I
Firm Address r 1� - L
`?tf.C[a. !
Gauge # G +��i?�'" /f� �
Date last accuracy tested / z- - /Z --/ %3
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy