2012_0525 (11)CIIECK ONE.
IRRIGATION DOMESTIC ��.�'� FIRELINE
BACI�ZOW PREVENTION ASSEMBLY TEST AND MAIN'I°ENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacl�low prevention assembly derailed below has been trsted and maintained as required by TNRCC
rcgulauons and is certified to be operating within acceptable parametrss_
TYPE OF ASSEMBLY
C Reduced Pressure Principle t�' Pressure Vacua Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer � � Size ='1 ` j
�:
Model Number t `' � � ,'� Located At � !� � - -- -
Serial Number � � ` `�
The above is certified to be uve.
Firm Name � .. ._: ,, ..,- r' Ceafied Teste ,.
Firm Address Cert. Tester No. � . ,- � � Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B��AE�R
Double Cher3c Valve Assembly
1st Chec1:
2nd Cbecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight o
Closed Tight O
Leaked o
Opened at
vsid
Opined at
nsid
nsid
RP- vsid
Leaked p
Did not Opm o
Leaked �
�P� „'`
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opened at
vsid
nsid
RP sid
The above is certified to be uve.
Firm Name � .. ._: ,, ..,- r' Ceafied Teste ,.
Firm Address Cert. Tester No. � . ,- � � Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy