2012_0117 (10)CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACK%Z.OW PREVENTION ASSEMBLY TEST AND MAII�iTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The baci�low prevention assembly detailed below has bees 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 Prrssttrc Vactm**+ Brzaker
Double Check Valve � Atmosphere Vacuum Breaker
Maaufactaffer Size �"
Model Number - � Located At >' rc ", _' "'r
Serial Number = '
The above is certified to be true.
Firm Name
Firm Address -_ - '
Gauge #
Date last accuracy tested
Certified Tester _ -
Cert Testa No. ' ' Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFZFA►�'R
Double Cheek Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Tight �
Closed Tigl}t O
Leaked �
Opened at
vsid
Opened at
osid
vsid
�_ vsid
'
Leaked o
Did not Opea o
Leaked �
Rcpatts
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
vsid
Opened at
vsid
osid
RP std
The above is certified to be true.
Firm Name
Firm Address -_ - '
Gauge #
Date last accuracy tested
Certified Tester _ -
Cert Testa No. ' ' Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy