2011_0812 (3)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: j - � � S ' � � `�J�
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Rcduc� Presstxrc Principle o Pressure Vac's***+ Breaker
Doable Checlr Valve o Atmosphere V`ac`aum'Brcaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Addtrss _
Gauge #
Date last accuracy tested
Certified Tester
Cent_ Testa No.
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�'R
Double Check Valve Assembly
1st Cheek
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DGCloscd
Closed Ti�hc o
Opened at
Opened at
nsid
Ti_ehi o
Leaked �
nsid
nsid
RP- osid
t 1• i� p
Did not Opea o
Leaked �
�P�s
and
Materials
Used
_
Test Agar
DC- Closed
Closed Tight a
Opened at
Opened at
nsid
Repair
Tight o
nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Addtrss _
Gauge #
Date last accuracy tested
Certified Tester
Cent_ Testa No.
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy