2012_0117 (9)CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE �`"
BACTCF'LOW PREVENTION ASSEIrIBLY TEST AND 1rIAII�ITENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ���� - �� %f,(! h�/+' /.`l <f�
The bacld;low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be opQating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacutnn Breaker
r*' Double Check Valve � Atmosphere Vacuum BreakQ-
Manufacttffer � Size --
Model I�+ttmbcr - ' Located At ; / . r
Serial Number
The above is certified to be true.
Firm Name Certified Tester
Firm Address � ' Cent Tester No. � Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'A�R
Double Chezk Valve Assembly
1st Chekl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight �
Closed Tight; �
Leaked? O
Opened at
nsid
Opined at
nsid
nsid
RP- vsid
Leaky o
Did not Opm o
Leaked '�
Repairs
and
Mata-ials
Used
Test Auer
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
nsid
Opened at
vsid
nsid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address � ' Cent Tester No. � Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy