2011_1128CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE �' -
BACK%Z.OW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME of Pws: CITY OF COPPELL
PWSLD. # C� ✓, l� c�o� �- c���.� -ion
LOCATION OF SERVICE: � /� /O _5 f-� o�i. / L
The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulatiotas and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
c Rcduccd Pressure Principle a Pressure Vaculnn Breaker
r?'� Double Check Valve � Atmosphere Vacuum Breaker
Maaufactlzrer Sir .
Model Nlmaber Located At l.: ' , . ' ,•-- l :. � .
Serial Number
The above is certified to be tnlc.
Film Name - `
Firm Address -' ,
Gauge #
Date last accuracy tested
Certified Tester - - -
-Cent Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�'R
Double Cberlc Valve Assembly
1st Check
tad Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight d
Opened at
Opined at
nsid
Tight 0''
/
Leaked �
nsid
nsid
1tP- � �� DSld
Lcakcd o
'l 4l
Did not Opm o
Leaked �
Repaus
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be tnlc.
Film Name - `
Firm Address -' ,
Gauge #
Date last accuracy tested
Certified Tester - - -
-Cent Tester No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy