2012_0831CIIECK ONE.
IRRIGATION DOMESTIC FIRE LIN E
BACKFT.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE=
The bacitilow prcvmtion assembly detailed below has bem tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduc. -d Pressure Principle C Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Maaufacttaer
Model Number
Serial Number
Size
Located At
The above is certifiod to be true.
Firm Name _
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date _
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B���R
Double Check Valve Assembly
1st Check
2nd Cbecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight A
Opined at
Opined at
vsid
Tight ❑
Leaked �
vsid
vsid
RP- vsid
Leaked o
Did not Open o
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Ropair
Tight t7
vsid
vsid
RP std
The above is certifiod to be true.
Firm Name _
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date _
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy