2011_1118 (3)CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF Pws: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The bacidlow prevention assembly detailed below has been tested and maintained as rccluirod by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C �'� Pressure Vacua Breaker
� Doubic Check Valve � Atmosphere Vacuum Breaker
Manufact�ser
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 - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAiCF'R
Doubie Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight n
Closed Tight �3
Leaked o
Opened at
vsid
Opined at
vsid
vsid
RP- vsid
��� p
Did not Opm o
Leaked �
�P��
and
Materials
Used
__
Test Afirr
Repair
DC- Closed
Tight �
Closed Tight o
Opened at
vsid
Opined at
vsid
vsid
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 - Tester's Copy