2012_1026CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACI�T.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE: `� C� I�-i _TAX- �__.t/y �-�
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
rcgulatioris and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle a Pressure Vacuinn Breaks
Double Check Valve D Atmosphere Vacuum Brzaker
fi
Manufacturer ��'
Model Number ���
Seria! Number �/ '�i � �
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accttracy testes
Certified Testa
Cert. Tester No. Date
white - customers copy Yellow -City Copy Pink - Testers copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B�F'AT�'R
Double Check Valve Assembly
1st Check
?ad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight E1"
Opined at
Opened at
vsid
Tight o
Leaked o
vsid
osid
RP- vsid
Leaked o
Did not Opea o
Leaked o
Repairs
and
Materials
Used
Test Attu
DC- Closed
Closed Tight o
Opmecl at
Opened at
osid
Repair
Tight o
vsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accttracy testes
Certified Testa
Cert. Tester No. Date
white - customers copy Yellow -City Copy Pink - Testers copy