2012_1026CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacl�low prevention assembly detailed below has been � tested and maintained as required by TNRCC
rcgulatiozLS and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuum Breaker
^ -' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer �i?'LV S Size �
Model I�iumba ���� Located At i v �G��_
Serial Number � ��-t 0
The above is certified to be true.
Film Name S � -✓. ° � Certified Testa
Firm Address � �� e l� \`!`1C Cent Testa No. Date
Gauge # �n� �i�'s- ��
Date last a��ura�y testes /,� /l - ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY
PRESSiJRE VACUUM BFtF'�►�R
Double Cheek Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed I
Closed Tight o'
Opined at
Opined at
nsid
Tight �
Leaked o
nsid
nsid
RP- nsid
Leaked a
Did not Open o
i rat Hi �
Repairs
and
Materials
Used
Test Auer
DC- Closed
Closed Tight [7
Opined at
Opened at
nsid
Repair
Tight a
nsid
nsid
RP sid
The above is certified to be true.
Film Name S � -✓. ° � Certified Testa
Firm Address � �� e l� \`!`1C Cent Testa No. Date
Gauge # �n� �i�'s- ��
Date last a��ura�y testes /,� /l - ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy