2012_1130 (4)CIIECH ONE:
IRRIGATION
DOMESTIC
FIRELINE �� "`
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE:
The bacictlow prevention assembly detailed below has bees tested and maintained as required by TNRCC
rzQUlations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressime Principle a Pressure VacuL•*n Breaker
�- Double Cheek Valve o Atmosphere Vacuum Breaker
Maaufact�ser
Model Number
Serial Nzmzber
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRE_A�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Cheek Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tighe o:
Closed Tight Q:
Leaked o
Opened at
vsid
Opened at
vsid
vsid
Rp- vsid
�� p
Did not Open o
Leaked �
Rcpaus
and
Materials
Used
Test After
liapair
DC- Closed
Tight 0
Closed Tight o
Opened at
vsid
Opeaed at
vsid
vsid
Rp sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester
Cent. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy