2012_1026CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEA�LY TEST AND MAI2�iT'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE:
The baci�low prcvmtioa assembly detailed below has been tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve � Atmosphere Vaau� Breaker
Manufacturer
Modei Number
Serial Number
Size
Located At '-
The above is certified to be true.
Firm Name �� - G-cJ � � r--� Ca-tified Tester
Firm Address .�twF�{ir�ef _ � Cent Tester No_ Date
Gauge # /f � � / � S�
Date last accuracy tested /� �� ��
Wtute - 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
Check Valve
Initial Test
DC- Closed ;
Closed Tight d
Opened at
Opined aL
nsid
Tilt �
Leaked o
nsid
nsid
RP- nsid
Leaked D
Did not Opm o
Leaked �
RrPair�
and
Matrriais
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name �� - G-cJ � � r--� Ca-tified Tester
Firm Address .�twF�{ir�ef _ � Cent Tester No_ Date
Gauge # /f � � / � S�
Date last accuracy tested /� �� ��
Wtute - Customer's Copy Yellow -City Copy Pink - Tester's Copy