2011_0812CHECK ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVEN'T`ION ASSEMBLY TEST AND M.e►I1V'I'ENANCE REPORT
NAME OF Pws: CITY OF COPPELL � -.
PWS I.D. #
LOCATION OF SERVICE: I i t =; - '
The bacicflow ptavmtion assembly detailed below has bcm 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 Vacuimz Breaker
Double Check Valve D Atmosphere Vacuum Breaks
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Film Name � ' � -''� t
Firm Address ,� -
Gauge #
Date last accuracy tested
Certified Tester
Cert Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BZ!Z AT�R
Double Check Valve Assembly
1st ChecS:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight C7
Closed Tight �-
Leaked o
Opened at
vsid
Opined at
nsid
nsid
RP- nsid
Leaked t7
-
Did not Opm D
Leaked '�
Repairs
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight t7
Closed Tight O
Opined at
nsid
Opined at
nsid
nsid
RP sid
The above is certified to be true.
Film Name � ' � -''� t
Firm Address ,� -
Gauge #
Date last accuracy tested
Certified Tester
Cert Tester No.
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy