2012_0117 (16)CIIECK ONE.
IRRIGATION
DOMESTIC
�.
FIRELINE
BACiCFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �� %U =� % % %L��- ��C�hG/k
The bacl�low 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 Rcduccd Pressure Principle C Pressure Vacur**� Breaker
Double Check Valve o Atmosphere Vacuum Brew
�.�____r ....��.. - Sizes __ -
Modei Number i Located At L - � � .
Seriai Ntmmber
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested '
Certified Tester '
Cent Tester No..�`. ' Dace
White - Customer`s Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRx'AT�R
Double Cheek Valve Assembly
1st Check
2nd Cbeck
Relief Vaive
Air Inlet
Check Valve
Initial Test
DC- Closed
Tis?izt o
Closed Tight a
Leaked o
Opened at
nsid
Opmcd at
nsid
nsid
RP- nsid
��� p
Did not Open o
Leaked �
�Pa�
and
Materials
Used
Test Agar
Repair
DC- Closed
Tight �
Closed Tight o
Opined aL
nsid
Opeaed at
nsid
nsid
Rp sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested '
Certified Tester '
Cent Tester No..�`. ' Dace
White - Customer`s Copy Yellow -City Copy Pink - Testers Copy