2012_0927 (2)CHECK ONE= ,
IRRIGATION DOMESTIC FIRELINE � -'
BACI�ZOW PREVENTYON ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has been tested and =rfainra;ned as required by TNRCC
rceulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressuue Va�-ut•*n Breaker
^' Double Check Valve o Attnospherc Vacuum Breaker
Manufacturer
Model Iii umber
Serial Number
Size
Located AL
The above is certified to be true.
Fitm Name _ Certified Tester
Firm Address Cert. Tester No. Date
Gauge #
Dete Lest accuracy testes
White — Customer's Copy Yellow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRFAT�R
Double Check Valve Assembly
1st Chec3:
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight D"
Closed Tight o
Leaked o
Opened at
vsid
Opined at
osid
vsid
RP- vsid
��� p
Did noc Opm o
Leaked �
�P�s
and
Materials
Used
Test ARu
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
vsid
Opened at
vsid
vsid
RP sid
The above is certified to be true.
Fitm Name _ Certified Tester
Firm Address Cert. Tester No. Date
Gauge #
Dete Lest accuracy testes
White — Customer's Copy Yellow —City Copy Pink — Testers Copy