2012_0117 (22)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: � �� .�. � /,�lC �it�'�'�i7Cl.�
The baei�low prevention assembly detailed below has been tested and maintained ag I- equired by TNRCC
re_eulazions and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacutnn Breaker
�' Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size l -
Model Number - % Located At 1 -' % <: , �,
Serial Number <r= ::�
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_AT�'R
Double Cher3c Valve Assembly
1st Chec3c
2nd Checl:
Relief Valve
Air Inlet
Cbeck Valve
Initial Test
DC- Closed
Closed Tight ��
Opened at
Opined at
nsid
Tight e]
Leaked o
nsid
nsid
RP- nsid
Leaked o
Did not Opm o
Leaked �
Repaus
and
Materials
Used
Test AR,er
DC- Closed
Closed Tight [7
Opined at
Opined at
nsid
Repair
Tight 0
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