2012_0117 (8)CIiECK ONE=
IRRIGATION DOMESTIC FIRELINE `
BACKFI,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: / �%O J /� %/ic_ H.C����U�f'
The bacicllow prevention assembly detailed below has beta 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 Vacuttm Breaker
3" Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size :'
Model I�iumber Located At '!= �� : - -' =�= , /`1
Serial Number 1 _ -, --
The above is certified to be true.
Firm Natve - , - Certified Tester --
Firm Address !- Cert Tester No �- i "' Date _
Gauge # � � ---;
Date Iast accuracy tested � � --
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA�R
Double Check Valve Assembly
1st Check
tad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight - D
Closed Tight o
Leaded o
Opened at
vsid
Opined at
vsid
vsid
' '
RP- osid
��� p
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test ARtr
Repair
DC- Closed
Tight o
Closed Tight 0
Opined at
vsid
Opened at
vsid
vsid
RP sid
The above is certified to be true.
Firm Natve - , - Certified Tester --
Firm Address !- Cert Tester No �- i "' Date _
Gauge # � � ---;
Date Iast accuracy tested � � --
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy