2012_0525 (6)CIIECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACI�FI,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE: /o�� . l� ��f /, > /� �; �� �G��� // i� =' 4� =�
The bacidlow prcvmtion 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 � Pressure Vacuum Breaker
Double Check Valve D Atmosphere Vacuum Breaks
Manufactaaer Sizc
Model Number Located At
Serial Number
The above is certified to be true.
Film Name -; �, %= �• ; '� - Certified Tester
�� ,
Firm Address %rte /��'�y y/� Cert. Tester No. Date
Gauge # oi�SoSl%
Date last accuracy tested _
i - //
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight D
Closed Tight o
Leaked D
Opined at
vsid
Opined at
'� osid
vsid
iz.P- osid
I.ealed p
Did not Opm o
Leaked '�
Repairs
and
Materials
Used
Test Aftrr
Repair
DC- Closed
Tight []
Closed Tight D
Opined at
osid
Opined at
osid
osid
RP sid
The above is certified to be true.
Film Name -; �, %= �• ; '� - Certified Tester
�� ,
Firm Address %rte /��'�y y/� Cert. Tester No. Date
Gauge # oi�SoSl%
Date last accuracy tested _
i - //
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy