2011_0812 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACK.FLOW PREVENTION ASSEI►�IBLY TEST AND M.,INTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE_ � �^ �- �OL� __ _ _
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations aad is certified to be operating within acceptable paramctus_
TYPE OF ASSEMBLY
e Rcdu� Pressure Principle C Pressure Vacsimi Brraker
Double Chtc1:'�Vaivc _ 0 „Atmosphere Vhctrui� Brealcei''_ _.._ .
Maaufacta>ter
Model Number
Serial Ntmmber
Size
Located At
The above is certified to be tzue.
Firm Name
Firm Addrrss _
Gauge #
Date last accuracy tested
Certified Tester
CerL Tester No.
- Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V ACWM BRFarr�'R
Double Chec3c Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Cioscd
Tight o
Closed Tight n
Leaked D
Opined at
vsid
Opined at
osid
vsid
RP- osid
u�;� p
Did not Opm o
Leai:ed �
�P�Ts
and
Materials
Used
-
Test After
DC- Closed
Closed Tight o
Opined at
Opened at
o_ sid
Repair
Tight �
vsid
osid
RP sid
The above is certified to be tzue.
Firm Name
Firm Addrrss _
Gauge #
Date last accuracy tested
Certified Tester
CerL Tester No.
- Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy