2011_1128 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE ��'
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANC7r REPORT
NAME OF PWS: CITY OF' COPPELL
PWS LD. # G(� , \�\ 1�., a �o< <. �-.a r-�
LOCATION OF SERVICE= S /-�c „ice. l
The baclfllow prcvmtion assembly detailed below has bem tested and ma;n ;�+ed as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C _ Rtduced Pressure Principle C Pressure Va�-vz***+ Br�caker
�'” Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer ' - Size �.
Model Number �'' ' " -% � ;'�. Located At L -' <;.. ,. / ; i`�' T , ,; -.
Serial Number � ' ' =�
The above is certified to be trot.
Firm Name
Firm Address
Gauge # <<_
Date last accuracy tested
_ Certified Testa -' f =,
_ Cent Tester No. Dau
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Checl:
tad Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opined at
nsid
Tieist C3'"
Leaked C
vsid
nsid
`
RP- nsid
��� C
`
Did not Opm o
Leaked C
Repairs
and
Materials
Used
Test A8a
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight 0
nsid
nsid
RP sid
The above is certified to be trot.
Firm Name
Firm Address
Gauge # <<_
Date last accuracy tested
_ Certified Testa -' f =,
_ Cent Tester No. Dau
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy