2012_0316CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACTCFI,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: '�U y A ! l � I��4 J . i<
The bacl�low prevention assembly detailed below has bees tasted and maintained as required by TNRCC
regulations aad is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure VacuLmm Breaker
�' Double Check Valve � Atmosphere Vacuum Breaker
Manufacttaer Size J � t{
Modei Number ' Located At �1i1' � 1 %�� t.t � --
Serial Number � ' + l' ' .�� `
The above is certified to be true_
Firm Name �nC-� � + t rZl- . - Certificcl Tester n � -
Firm Address 1 `D t� � Y %l1 % [re k.� xL-: 1� c. L � Gtr Cent. Tester No. : � -< Date
--('. .
Gauge # C? (-� � � bU% ��
Date last accuracy tested � �/5! � I
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Cbeci:
Initial Test
DC- Closed
Tight �-
Closed Tight �
Leaked o
Opined at
nsid
Opined at
nsid
nsid
RP- nsid
�� p
Did not Opm o
Leaked �
Repairs
and
Materials
used
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
nsid
Opined at
_nsid
nsid
RP sid
The above is certified to be true_
Firm Name �nC-� � + t rZl- . - Certificcl Tester n � -
Firm Address 1 `D t� � Y %l1 % [re k.� xL-: 1� c. L � Gtr Cent. Tester No. : � -< Date
--('. .
Gauge # C? (-� � � bU% ��
Date last accuracy tested � �/5! � I
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy