2011_0725 (2)CIIECK ONE. �r
IRRIGATION DOMESTIC ' l� FIRELINE
BACKFI.OW PREVEN'T'ION ASSEA�LY 'PEST AND A3AII�ITENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacl�low prevention assembly detailed below has been tested and main a;ned as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYFE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vac -ut***+ Breaker
Double Check Valve D Atmosphere Vacuum Breaks
Manufacitser • "� Size
Model Number
Serial Number
`�
Located AL
f ".e �, ._.,,_
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent Tester No.
Date
Wtute — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BFtFAKF'R
Double Check Valve Assembly
1st Chee1:
2nd Cheek
Relief Valve
Aic Inlet
Cheek Valve
Initial Test
DC- Closed
Tight �
Closed Tight �
Leal:cd �
Opened at
nsid
Opined at
nsid
nsid
RP- nsid
��� Q
Did noc Opm o
Leaked �
�P��
and
Materials
Used
Test ARcr
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opined at
nsid
nsid
RP sid
The above is certified to be true_
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent Tester No.
Date
Wtute — Customer's Copy Yellow —City Copy Pink — Tester's Copy