2012_1025 (2)CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEIVlBLY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The baci�low prcvmtiott assembly detailed beiow has bcm tested and ma;nrained ag required by TNRCC
zcgttlarions and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
c Reduced Pressure Principle a Pressure Vacuum Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Maaufacttacr Size
Model Ntmmber Located At
Serial Number
The above is certified to be true.
Film Name ' �W %ii'�-
Firm Address L'� ��•�`
Gauge # !1���_�'s
Date Last accuracy tested
Certified Tester
Cent. Testa No.
Date
White - Customer`s Copy Ye11ow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'A�'R
Doubie Cheek Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight [7
Closed Tight o
Leaked -�_
- -Opined at
vsid
Opined at
vsid
vsid
RP- vsid
�� .�'�
Did noc Opm o
Leaked �
Repairs
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight 0
Closed Tight o
Opined at
vsid
Opined at
vsid
vsid
RP sid
The above is certified to be true.
Film Name ' �W %ii'�-
Firm Address L'� ��•�`
Gauge # !1���_�'s
Date Last accuracy tested
Certified Tester
Cent. Testa No.
Date
White - Customer`s Copy Ye11ow -City Copy Pink - Tester's Copy