2012_0316 (2)CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The baci�low prevmtioa assembly detailed below has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c Reduced Pressure Principle c Pressure Vacua•**+ Breaker
*.,1 Double Check Valve 0 Atmosphere Vacuum Breaker
,'� : ;
Manufacturer Size `�
Model Number -, Located At � J�1E � �' �'t—'-
Serial Number
The above is cctified to be true.
Firm Name � � _ Cctified Tester �' � -' <-- ° ` -- - T
,._ ,
Firm Address . Cest_ Testa No. fi'< +�� � i Date �T, __
Gauge #
Date last accuracy tested ���j l�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B���R
Double Check Valve Assembly
Relief Valve
Air Inlet
Cheek Valve
1st Cheek
2nd Cheek
Initial Test
DC- Closed
TiahL �
Closed Tight �
Leaked �
Opined at
osid
Opened at
nsid
nsid
RP- osid
I.ealed p
Did not Open �
Leaked �
Rcpaus
and
Materials
Used
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
nsid
Opined at
osid
nsid
RP sad
The above is cctified to be true.
Firm Name � � _ Cctified Tester �' � -' <-- ° ` -- - T
,._ ,
Firm Address . Cest_ Testa No. fi'< +�� � i Date �T, __
Gauge #
Date last accuracy tested ���j l�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy