2012_1026CHECK 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 baci�low prcvmtioa assembly detailed below has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
r3 Double Check Valve
Manufacturer �s��>Ll�"� S
Model Number ���
Serial Number �� 1�� 5--�
TYPE OF ASSEMBLY
e Pressure Va�-+�+�**+ Breaker
o Atmosphere Vacuum Breaker
Size
Located AL
The above is ce�fied to be true.
Firm Name � � • /�• � �_"':= Certified Tester _ ;- ,
Firm Address �QiVS i �° � � CCrL Tester No. Date
Gauge � /C?� � / �S6
Date last accuracy tested �� �� ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_�►T�R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tip_ ht 0'
Opined at
Opined at
vsid
Ti_eht -�
Leaked s o
vsid
osid
RP- vsid
Leaked o
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opeaed at
vsid
Repair
Tight t7
nsid
asid
RP std
The above is ce�fied to be true.
Firm Name � � • /�• � �_"':= Certified Tester _ ;- ,
Firm Address �QiVS i �° � � CCrL Tester No. Date
Gauge � /C?� � / �S6
Date last accuracy tested �� �� ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy