2012_0523CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACT�F'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow prcvmtion assembly detailed below has bem tested and maintained as required by TNRCC
reQttlacions and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve � Atmosphere Vacuum Breaker
Maaufarnaer
Model Number
Serial Number
Size
Located AL
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�'R
Doubie Check Valve Assembly
Re3ief Valve
Air Inlet
Check Valve
1st Check
2nd Cheek
Initial Test
DC- Closed
TiehL �
Closed Tight . �
Leaked t7
Opined at
osid
Opined at
osid
nsid
RP- nsid
�� p
t
Did not Opm D
Leaked �
�P��
and
Materials
Used
Test After
Repair
DC- Closed
Tight �
Closed Tight t]
Opined at
vsid
Opined at
nsid
osid
Rp sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy