2012_1130 (2)CHECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACTCFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The bacl�low prevention assembly detailed below has bees tested and maintained as required by TNRCC
reQUlations and is certified to be operating within acccptablc parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle a Pressure Vacuum Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Maaufactaaer
Model Number
Serial Number
Sizc
Located AL
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BIZFAxF'R
Double Chec3c Valve Assembly
Relief Valve
Air Inlet
Cheek Valve
1st Check
2nd Cheek
Initial Test
DC- Closed
Closed Tight �'
Opened at
Opened at
vsid
Tight D
Leaked [7
vsid
vsid
Rp- vsid
��� p
Did not Opea o
Leaked �
Repairs
and
Materials
Used
Test A.Rtr
DC- Closed
Closed Tight �
Opmed at
Opened at
vsid
Repair
Tight �
vsid
vsid
Rp std
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy