2012_1026CHECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACICFI.OW PREVENTION ASSE1rIBLY TEST AND MAINTENANCE REPORT
M��T��i�a���ib'i
PWS I_D_ #
CITY OF COPPELL
LOCATION OF SERVICE: �(��Fl �^�,6k�t/� -td ��
The bacicflow prcvmtion assembly detailed below has bem tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
e Reduced Pressure Prmcrple
�. Double Check Valve
Manufacturer ,`"-��YYhP 5
Model Number � � °��°�'�
Serial Number r - ?�r�3
TYPE OF ASSEMBLY
C Pte55ure V a�'+'+**^ Breaka
o Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name > � � � r�-
Firm Addtzss •�
Gauge # � tip %/MS'S
Date last accuracy tested �� -- �� — ��
Certified Testa
Cent. Testa No,
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA�'R
Double Cheek Valve Assembly
1st Check
tad Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tighe �
Opined at
Opined at
nsid
Tight Q
Leaked- 0
vsid
nsid
RP- nsid
�� p
Did not Opm O
Lcaled �
Repairs
and
Materials
Used
Test Afia
DC- Closed
Closed Tight v
Opeaed at
Opined at
nsid
Repair
Tight a
nsid
vsid
RP sid
The above is certified to be true.
Firm Name > � � � r�-
Firm Addtzss •�
Gauge # � tip %/MS'S
Date last accuracy tested �� -- �� — ��
Certified Testa
Cent. Testa No,
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy