2012_0412 (2)CHECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � � �� L' � 1-�Ca �idC �- �c'.c —E'
The baclfllow prevention assembly detailed below has been tested and main a�r� as rrgtrired by TNRCC
tzgttlarions and is certified to be operating within acceptable patametas_
TYPE OF ASSEMBLY
C Reduced Pressure Principle c Pressure Vacui�±+ Breaker
'?" Double Check Valve o Amzospherc Vacuum Breaker
r
Manufacturer J- � � S � -F �?� Size -
Model Number � C Located At r -
serial Ntrmber � C� f ) �- 3
The above is certified to be true_
Firm Name � Cetified Testa
Firm Address ., ; ` < � Cert Tester No. - Date
Gauge #
Date last accuracy tested �` . c
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF_AKFR
Double Cheek Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed ' - `'�
Closed Tight a
Opened at
Opined at
nsid
Tight Q
Leaked D
nsid
nsid
RP- nsid
r` r
Leaked o
Did not Opm o
Leaked �
�P�s
and
Mata-ials
Used
Test Aiirs
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true_
Firm Name � Cetified Testa
Firm Address ., ; ` < � Cert Tester No. - Date
Gauge #
Date last accuracy tested �` . c
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy