2011_0812 (5)CIIECK ONE.
IRRIGATION DOMESTIC FIRELIN E
BACi�T.OW PREVENTION ASSEIrIBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has been tested and }rfa;nrained a5 required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
c Reduced Pressure Principle C Pressure Vacutmm Breaker
Double Check Valve D Atmosphere Vacuum Brcal:er
Manufacturer
Model Number
Serial Nt>mber
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
C�?�s�?
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE2VIBLY
PRESSURE VACWM BR�'A�'R
Double Check Valve Assembly
1st Check
2nd Cbecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�hc a
Opined at
Opined at
nsid
Ti>dzt o
Leaked o
nsid
nsid
RP- vsid
Leaked o
Did not Opm O
Leaked �
�Paz�
and
Materials
Used
`
Test ARer
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight Q
nsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
C�?�s�?
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy