2012_0117 (12)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: � I % %G ,�h' %/ /yam
The bacicflow prevention assembly detailed 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 C Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size -
Model Number � Located At -
Serial Ntmzber -
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Tester
Cent Tester No_ Date
Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Chen:
tad Cheri:
Relief Valve
Air Inlet
Chec3c Valve
Initial Test
DC- Closed
Tishi D
Closed Tight o
Leaked D
Opined at
nsid
Opined at
osid
nsid
RP- nsid
��� p
Did not Opm D
Leaked �
�Pa„t
and
Materials
Used
Test Af%r
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
osid
Opened at
osid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Tester
Cent Tester No_ Date
Yellow —City Copy Pink — Tester's Copy