2012_1026CHECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: E--� S� `' � e.r -*-�
The bacicflow prevention assembly derailed below has bees tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduocd Pressure Principle C Pressure Vacuum Breaker
Double Check Valve D Atmosphere Vacuum Breaker
Manufacttaer ��'1'� �'� Size
Model Number � �f'Y)f/77r�� _ Located At f
Serial Number � � ��`?' `
The above is certified to be true.
Firm Name
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJ'CTM B��F►i�R
Double Check Valve Assembly
1st Check
2nd Checi:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight el
Closed Tight Q.
Leaked o
Opened at
vsid
Opened at
nsid
nsid
RP- vsid
��� p
Did not Open o
Leaked �
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight �
Opened ai
vsid
Opened at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy