2012_1026CIIECK ONE=
IRRIGATION DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C /TY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The baci�low prevention assembly detailed below has been testcd and ma;ntai_*±ed as required by TNRCC
rcgulations and is certified to be operating within acccptablc parameters.
TYPE OF ASSEMBLY
c Rcduc. -d Pressurc Principle C Pressurc Vactnrm Brcaktr
Doublc Check Valvc � Atmosphere Vacuum Breaker
Manufacturer �'�-.i 9.'L� S Size / �tl
Modci Ivumbcr 6�����, / Located At l 4!
Serial Number � �� � `f
The above is certified to be true_
Firm Name G_ - -__ -.
Fitm Address
Gauge #
Date last accuracy tested
White - Customer's Copy
Cctied Tester . �_ - -
Cent Tests No. Date i'
Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BR�A�'R
Double Check Valve Assembly
1st Cheek
2nd Checl:
Retie{ Valve
Air Inlet
Check Valve
Initial Test
DC- Closed. _ �
"Q",
Closed Tight C1"�
Opened at
Opened at
nsid
Tight
Leaked -' o
nsid
nsid
RP- nsid
L�;cd �
Did not Open o
Leaked �
Rcpairs
and
Materials
Used
Test Agar
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true_
Firm Name G_ - -__ -.
Fitm Address
Gauge #
Date last accuracy tested
White - Customer's Copy
Cctied Tester . �_ - -
Cent Tests No. Date i'
Yellow -City Copy Pink - Tester's Copy