2012_0117 (7)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
i.C)CATiC71v CAF SERVICE_ li'�'f� _�. / / %/,Y'f%/C'�
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable pararacters.
TYPE OF ASSEMBLY
c Reduced Pressure Principle C Pressure Vacutmm Brt:alcer
^� Double Check Valve � Atmosphere Vacuum Breaker
Maaufacttn•er < -�.- Sizc
Model Number --J Located At � , , ;
Serial Number -% � � - --
The above is certified to be true.
Firm Name Certified Tester y-
Firm Address " Cent Tester No.- r Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFL AT�'R
Double Check Valve Assembly
1st Checl:
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Tight D
Leaked o
vsid
osid
RP- vsid
Leaked o
Did noc Opm o
Leaked 'J
�P�
and
Materials
Used
Test Agar
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name Certified Tester y-
Firm Address " Cent Tester No.- r Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy