2012_0608CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The bacicflow prevmtioa assembly detailed below has bem tested and mainfained as required by TNRCC
rcgulacions and is certified to be operating within acceptable paramcters_
. � TYPE OF ASSEMBLY � ,
C Reduced 1�'ressurc Principle T C pressure Vacutnn Breaker
�' Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Szzc
Model Number
Serial Number
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
Certified Testa
Cat Tester No. Date
TUM BREAKER
Cheek Valve
vsid
Leaked �
vsid
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSi1RE PRINCIPLE ASSEMBLY
PRESSiIRE VACI
Doubie Check Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight e" ,
Opened at
Opened at
Tight o'
Leaked o
vsid
osid
RP- vsid
I.ealed p
Did not Opm o
gcPaiT�
and
Materials
., �
t
t
Used
,
Test Afia
DC- Closed
Closed Tight o
Opened at
Opined at
Repair
Tigitt �
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
Certified Testa
Cat Tester No. Date
TUM BREAKER
Cheek Valve
vsid
Leaked �
vsid
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy