2012_0525 (5)CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACK%ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: /O %S S %���i�> f� <� ��G� �7.� —// 7� �%'G /;
The bacidlow prevmtioa assmzbly detailed below has bem tested aad maintained as required by TNRCC
rcgularions aad is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Presstac Principle , =� Pressure Vacutmz Breaker
Double Chak Valve o Atmosphere Vacuum Breaker
Maatifacttaer Size
Model Number
Serial Ntmmber
Located As
The above is certified to be true.
Firm Name <. Certified Testa -” � "� r -
Firm Address - - Cent. Testa No. ,- `. Date `" ' . - -
Gauge # ""
Date last a��ura�y testes
Wtrite — Customer's Copy Yellow — Cfty Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR>: ascF'R
Double Check Valve Assembly
1st Check
2nd Cheek
Relief Valve
Air Inlet
Cheek Valve
hzitial Test
DC- Closed
Tilt o
Closed Tight a
Leaked o
Opened at
vsid
Opined at
nsid
nsid
RP- nsid
Leaked o
Did not Opm O
Leaked �
R=Pa „t
and
Materials
Used
Test Af3a
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
vsid
Opined at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name <. Certified Testa -” � "� r -
Firm Address - - Cent. Testa No. ,- `. Date `" ' . - -
Gauge # ""
Date last a��ura�y testes
Wtrite — Customer's Copy Yellow — Cfty Copy Pink — Tester's Copy