2012_1012CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD_ # k:c��a -i �Ji -1t��
LOCATION OF SERVICE: � Z � j� r.J �c.�j ti'Y �� -
The bacicflow 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 ASSE2vIBLY
C Reduced Pressure Principle C Pressiuc Va�-+n***+ Breaker
�' Double Check Valve o Atmosphere Vacuum Breaker
Maaufactrner Size
Model Number - Located At ' � � � � �
Scx-ial Number .
The above is cer-tificd to be true_
Firm Name Certified Tester
Cert. Tester No. ? Date
Firm Address
Gauge # �: � G 3 L S
Date Last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREA>!�R
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight
Opined at
Opened at
nsid
Tight ��
Leaked 4
nsid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked o
�P��
and
Materials
Used
Test Aftrs
DC- Closed
Closed Tight o
Opined at
Opined at
� sid
Repair
Tight a
nsid
nsid
RP sid
The above is cer-tificd to be true_
Firm Name Certified Tester
Cert. Tester No. ? Date
Firm Address
Gauge # �: � G 3 L S
Date Last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy