2011_0812 (4)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACI�'I.OW PREVENTION ASSEMBLY TEST AND MAIN'I'ENANC� REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: _ �_� � 5 . � O (.,�
The bacl.-flow prevention assembly detailed below has been tested and maintained as requirzd by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Var+n�*++Breaktr
Double Check Valve o Atmosphere Vi<cirum BreaI-er
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name _
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSE1V18LY
PRESSURE VACLTCTM
Bl2FA�'R
Double Check Valve Assembly
1st Check
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Tight o
Leaked �
nsid
osid
RP- nsid
Lcai:ed O
Did not Opm D
Leaked �
Repairs
and
Materials
Used
Test ARc
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Name _
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy