2014_0406CIIECK ONE:
,/
IERIGATION DOMESTIC FIRELINE l�
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. #
LOCATION OF SERVICE: � ��� �� l/ % � �
The bacicflow prevention assembly detailed below has bees tested and ma;nra;�+ as required by TNRCC
rzgulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuran Breaker
�} Double Check Valve � Atmosphere Vacuum Breaker
Maaufacuaer �/` � �/ S Size ��
Model riumber 7 � y Located At � /? � �
Serial Number � / G G o
The above is certified to be true.
Firm Name /7 c �� o �� / �� C °' Certified Tester !�'�. ��� Gf/, ll� i iu �
Firm Address P' U . i3" y 7 `f 7 C�/r* t�1-� Cer�t Tester No. />' � Date � -G -/ y
jh r
�5(Co�
Gauge # UT G� �' `1/ 7 4' G'
Date last accuracy tested 3 -� � " �
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B RF�T� R
Double Cheek Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tirdrt �• G �
Closed Tight '�
1 -caked :� � �
Opined at
o sid
Opened at
o sid
n sid
RP- n sid
�� p
Did noc Open O
Leaked �
��
and
� � ���� Q
/" � l c
_ L %4 �v -�
Materials
Used
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
o sid
Opined at
n sid
n sid
RP aid
The above is certified to be true.
Firm Name /7 c �� o �� / �� C °' Certified Tester !�'�. ��� Gf/, ll� i iu �
Firm Address P' U . i3" y 7 `f 7 C�/r* t�1-� Cer�t Tester No. />' � Date � -G -/ y
jh r
�5(Co�
Gauge # UT G� �' `1/ 7 4' G'
Date last accuracy tested 3 -� � " �
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy