2012_1030CIIECK ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFi.OW PREVENTION ASSEA�LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacl�low prcvmuon assembly detailed below has been tested and xna;nta�*+ed as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pmstrrc Principle a Pressure Vacuttm Breaker
Double Check Valve � Atmosphere Vacuum Breaks
Manufacturer Sizc
Model Nmmba
Serial N�ber
Located At
The above is certified to be true.
Firm Natne
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No. Date � '� "'
�,
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1rIBLY
PRESSURE VACUUM BREAKER
Double Cheek Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight a
Opined at
Opined at
nsid
Tight. �
Leaked o
nsid
� sid
RP- vsid
Leaked a
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight a
Opened at
Opined at
� sid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Natne
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No. Date � '� "'
�,
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy