2012_0821CHECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFI..OW PREVENTION ASSEMBLY TEST AND MA.IIVT'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: - i .' � � :` �� r.
The bacicflow prevention assembly detailed below has beta tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_ t
TYPE OF ASSEMBLY
C Rcduccd Pressure Principle C Pressure VacuL�*n Breaker
�J' Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model I�itmiber
Serial Nttmber
Size
Located At
The above is certified to be trite.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent. Tester No Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT�'R
Double Checlt Valve Assembly
1st Check
tad Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opined at
nsid
Tight Q
Leaked o
osid
osid
RP- '' nsid
Leaked o
Did not Open o
Leaked �
�Paz�
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Repair
Tight o
vsid
osid
RP std
The above is certified to be trite.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent. Tester No Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy