2012_1130 (3)CIIECK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACKFi.OW PREVENTION ASSEMBLY TEST AND MP►INI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE:
The bael�low prevention assembly detailed below has bem tested and maintained as regtnred by TNRCC
reeulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Va�-uL�*n Breaker
Double Check Valve � Atmosphere Vacuum Breaks
Maaufacnacr Size
Model Ntnnber Located AL
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Carcified Testa
Cart Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Taster's Copy
REDUCED PRESSURE PRINCIPLE ASSE2�IBLY
PRESSURE VACUUM BRE_AT�'R
Double Cheek Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
tad Cheel:
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Tight D
Leaked 0
vsid
vsid
Rp- vsid
��� p
Did not Opea o
Leaked �
RePair-�
and
Materials
Used
Test Attu
DC- Closed
Closed Tight v
Opined at
Opened at
vsid
Repair
Tight �
vsid
vsid
Rp sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Carcified Testa
Cart Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Taster's Copy