2012_1026CIIECK ONE.
LR.RIGATION DOMESTIC FIRELINE --
BACI�'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has bees tested and �a�++ta��+ed as requirzd bw TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Rcduccd Pressurz Principle a Pressure Vac**+***+ Breaker
��: Double Check Valve o Atmosphere Vacuum Breaker
Manufaciaaer Sizc
Model Number � Located At -
Serial Number
The above is certified to be true.
Firm Name �� . � i �'�-
Firm Address ���� � �- -
Gauge # _•�( -� -J� /�_S �a
Date last accuracy tested !�- �f� —��
Certified Tests
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�'R
Double Cber3c Valve Assembly
1st Check
?nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closeai
Closed Tight t� �
Opened at
Opened at
osid
_
Tight e7
Leaked a
osid
osid
RP- osid
Lcal:ed p
Did not Opea o
Leaked �
�P�s
and
Mata-ials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight �
osid
osid
RP sid
The above is certified to be true.
Firm Name �� . � i �'�-
Firm Address ���� � �- -
Gauge # _•�( -� -J� /�_S �a
Date last accuracy tested !�- �f� —��
Certified Tests
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy