2012_1004CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELIN E
BACI�ZOW PREVENTION ASSEMBLY 'PEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacl�low prevention assembly detailed beiow has been tested and ma,nra *ned as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
c Reduced Pressure Principle C Pressure Vaevu**+ Breaker
^ Double Check Valve 0 Atmosphere Vacuum Breaker
Maaufacnaer
Modes Number
Serial Number
Size
Located At
The above is certified to be true.
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Firm Address
Gauge #
Date lest accuracy tested
Certified Tester
Cost Tester No: Date
White - Customer's Copy Yellow -City Copy Pirtle - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJTJM BRFairPR
Double Check Valve Assembly
1st Cheek
tad Checl:
Relief Valve
Air Islet
Cheek Valve
Initial Test
DC- Closed
Closed Tight O
Opened at
Opined at
vsid
TiQhL Q
Leaked o
vsid
vsid
RP- vsid
Lcal:ed D
Did not Open o
Leaked �
Repairs
and
Materials
Used
Test ARrs
DC- Closed
Closed Tight o
Opened at
Opined at
vsid
Repair
Tight �
vsid
vsid
RP rid
The above is certified to be true.
�� :'r�:F1::fy
Firm Address
Gauge #
Date lest accuracy tested
Certified Tester
Cost Tester No: Date
White - Customer's Copy Yellow -City Copy Pirtle - Tester's Copy