2012_1026CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFT�OW PREVENTION ASSEII�LY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
�%
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaks
Manufactsaer Sue �
Model Number
Serial Number
- Located At
The above is ca-aificd to be true.
Firm Name �'liL% f! � /`�C/ � � �� /Certified Tester
Firm Address ` r o0 Zi.h� � i� �- �'li�`�/`.�1`'�cert. Tester No. Date r%'=.
1
Gauge # /� � / �S �
Date last accuracy tested /� �� -,j"
White - Customer's Copy Yellow -City Copy Panic - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM Bix>:'ASCFR
Double Check Valve Assembly
1st Cheek
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
.Closed Tight ,�
Opened at
Opened at
nsid
Tight e1
Leaked �
nsid
nsid
RP- vsid
Leaked o
Did not Open o
Leaked '�
Rcparrs
and
Materials
Used
Test Afars
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight o
nsid
vsid
RP sad
The above is ca-aificd to be true.
Firm Name �'liL% f! � /`�C/ � � �� /Certified Tester
Firm Address ` r o0 Zi.h� � i� �- �'li�`�/`.�1`'�cert. Tester No. Date r%'=.
1
Gauge # /� � / �S �
Date last accuracy tested /� �� -,j"
White - Customer's Copy Yellow -City Copy Panic - Tester's Copy