2014_0406 (3)CIIECK ONE.
IRRIGATION
DOMESTIC � FIRELINE
BACZCFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
/ j
_.`/
LOCATION OF SERVICE: F t ( L F/��C�yr-�- ��-"-� C®ldp¢_�( "7�i � [y
The baelcflow prcvmtion assembly derailed below has bem tested and **�a +•+ta�*+ as required by TNRCC
rzgulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c /r Reduced Pressure Principle a Pressurt Va �+�•**+ Breaker
�/ Double Chcck Valve � Atmosphere Vacuum Breaker
_ 4✓
Maaufactra �O� t [�+=�5 Size
Model Number Q $O Located At F i r �e--. �TS�f' K d a/rr
Serial Number �' �Ol
The above is certified to be true.
Firm Name S �':s� ��ccs�, Certified Testa ® f�i���i� -v. �'/_. �F�.vc�S
Firm Address ..�FOa2 /IY �1 � J�r+ -. tee Cent Testa No/p PDU�A 3 7 8�- Date J� �l�/�✓
� scr j.�... / � ,�O `� �
Gauge # OS�' � 1 7 � �
Date last accuracy tested � - � �- !'�j�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B FtF'4�' R
Double Check Valve Assembly
1st Check
2nd Cheel:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed �. k
Closed Tim
Opined at
Opined at
n sid
P`���
Ti2hL
RP- n sid
Leaked , o
n sid
n sid
Leaked a
Did not Opm O
Leaked �
Repaus
sad
Materials
Used
Test Alts
DC- Closed
Closed Tight o
Opined at
Opined at
n sid
Repair
Tighe o
n sid
n sid
RP sid
The above is certified to be true.
Firm Name S �':s� ��ccs�, Certified Testa ® f�i���i� -v. �'/_. �F�.vc�S
Firm Address ..�FOa2 /IY �1 � J�r+ -. tee Cent Testa No/p PDU�A 3 7 8�- Date J� �l�/�✓
� scr j.�... / � ,�O `� �
Gauge # OS�' � 1 7 � �
Date last accuracy tested � - � �- !'�j�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy