2012_0709CfIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEA�LY TEST AND MAINTENANG� REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. #
LOCATION OF SERVICE:
The baci�low prcvmtion assembly detailed below has been tested and maintained as required by TNRCC
rc_eulanons and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure VacuL�*n Breaker
^" Double Cheek Valve � Atmosphere Vacuum Breaker
Maaufacttzrer
Model I�iumba
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cat Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAF�R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight �
Closed Tight ID
Leaked o
Opened at
vsid
Opened at
vsid
vsid
RP- vsid
Leered o
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tie,_,krt Q
Closed Tip,,ht o
Opined at
vsid
Opined at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cat Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy