2012_0117 (23)CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: --
The bacldlow pmmtioa assembly detailed below has bem tested and maintained as required by TNRCC
regulations sad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c Rcduc. -d Presstu-e Principle a Pressure Vacutnn Breaker
Double Check Valve D Atmosphere Vacuum Breaker
Maaufact�ser Size
Model Number
Serial N�ber
Located At
The above is certified to be true.
Firm Name Certified Tester
Firm Addms Cent Tester No. Date
Gauge # _
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRF'AT�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Tight D
Closed Tight 0
Leaked o
Opeaed at
nsid
Opined at
nsid
vsid
RP- nsid
Leaked o
�
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
nsid
Opined at
vsid
nsid
RP std
The above is certified to be true.
Firm Name Certified Tester
Firm Addms Cent Tester No. Date
Gauge # _
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy