2012_1105CIIECK ONE=
LRRIGATION
DOMESTIC
FIRELINE
BACICFLOW PREVENTION ASSEA�LY 'PEST AND MAINTENANCE'. REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. # 1
LOCATION OF SERVICE:
The bacicflow prcvmtion assembly detailed below has bcm tested 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 Vacumn Breaker
�?' Double Check Valve o Atmosphere Vacuum Breaker
i
Maaufactirrer Size ,.
Model Number Located At + �� ; t ° ; : �
Serial Nmmber .
The above is certified to be true_
Firm Nazne
Firm Address `
Gauge Ik
Date Iast accuracy tested
Certified Tester
Cent Tester No. � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJL7M BR��R
Double Cheek Valve Assembly
1st Check
2nd Checl:
'ef Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
� Closed Tight �'
Opined at
Opined at
nsid
Tight,
Leaked o
nsid
nsid
RP- nsid
Leaked o
Did noc Open o
Leaked �
Repairs
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Rtpair
Tight o
nsid
nsid
RP sid
The above is certified to be true_
Firm Nazne
Firm Address `
Gauge Ik
Date Iast accuracy tested
Certified Tester
Cent Tester No. � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy