2012_0117 (13)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE -
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �y� C' S . ✓off % /��- �} /� %/l �/K
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 Vacurnn Breaker
�" Double Check Valve � Atmosphere Vacuum Breaker
Maaufacttztcr - ,' _= Size -
Model l�iumber Located At
Serial Number
The above is certified to be true.
Firm Name '
Firm Address ' i
Gauge # -
Date last accuracy tested
Wtute - Customer's Copy
Certified Tester
Cent Testa No. Date
Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJ'[TM BRE_AT�'R
Double Chec3c Valve Assembly
1st Check
2nd Cbccl:
Relief Valve
Air Islet
Cheek Valve
Initial Test
DC- Closed
Tight o
Closed Tight. o
Leaked o
Opened at
osid
Opined at
osid
osid
RP- Dsid
I.ealed o
Did not Open o
Leaked o
Repairs
and
Mata-ials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
nsid
Opined at
osid
osid
RP sid
The above is certified to be true.
Firm Name '
Firm Address ' i
Gauge # -
Date last accuracy tested
Wtute - Customer's Copy
Certified Tester
Cent Testa No. Date
Yellow -City Copy Pink - Tester's Copy