2012_1029 (2)CIIECK ONE:
IRRIGATION _ /�� DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
_ i
LOCATION OF SERVICE: ` � "_ _ _ - � 'f ; '� r � i
The baci. -flow prcvmtioa assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating wiihia acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Va�-uL�**+ Breaker
Doubic Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Scrim Number
Size
Located At
The above is certified to be true.
Fitm Name � � '
Firm Address _
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No_ � Date � �' .�b y
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACULdM BRFA�'R
Double Chet3c Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight o
Closed Tight D
Leaked o
Opened at
nsid
Opined at
nsid
nsid
RP- nsid
��� p
Did not Opm o
Leaked �
Repairs
and
Mata-ials
Used
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opened at
vsid
Opined at
vsid
nsid
RP sid
The above is certified to be true.
Fitm Name � � '
Firm Address _
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No_ � Date � �' .�b y
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy