2012_0117 (20)CIIECH ONE.
IRRIGATION
DOMESTIC
.�
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �00 .-�. /7 %GAk' %�74�
The bacl�low prevention assembly detailed below has been tested and maintained as requited by TNRCC
zegulatioas and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Pzinciple C Pressure Vacut�**+ Breaker
Double Check Valve O Atmosphere Vacuum Breaker
Maaufactaffer � Size
Model Number Located At r, ; ,. -•
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent. Tester No• �`
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Check
tad Checl:
Relie {Valve
?lir Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight [3
Opened at
Opined at
osid
Tight Q
Leaked o
osid
osid
`
RP- nsid
�� �
Did not Opm o
Leaked �
�P�s
and
Matetials
Used
Test After
DC- Closed
Closed Tight t7
Opened at
Opined at
nsid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent. Tester No• �`
Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy