2012_0117 (3)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE -
BACKFT.OW PREVENTION ASSEA�LY TEST AND MAI2V'I'ENANCE REPORT
NAME OF Pws: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE= ,� % %.�k =f�K n � >,�
The baci�low prevention assembly detailod below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
c Reduced Pressure Principle a Pressure Vacsnnn Breaker
� Double Check Vaivc o Atmosphere Vacuum Breaker
Manufactan-er
Modes Number
Scrim Number
' Size
' Located At
The above is certified to be true.
i
Firm Name } ; ,
Firm Address
Gauge # - -
Date last accuracy tested
Certified Testa � , '. -;
Cent Tester No. ' Date
White - CustomeCs Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI�LBLY
PRESSURE VACUUM Bft��R
Double Check Valve Assembly
1st Check
2nd Cbecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Tight O
Leaked a
nsid
nsid
RP- nsid
I_.cal:ed p
Did not Opea o
Leaked c7
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight 0
Closed Tight o
Opined at
vsid
Opined at
nsid
nsid
RP std
The above is certified to be true.
i
Firm Name } ; ,
Firm Address
Gauge # - -
Date last accuracy tested
Certified Testa � , '. -;
Cent Tester No. ' Date
White - CustomeCs Copy Yellow -City Copy Pink - Tester's Copy