2012_0608CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELiNE
BACICi�ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: � / ~I ! Y� ( i C�- ti 1 t ,`. -ACA ?/
The bacl�low prevention assembly detailed below has been tested and maintained as required by TNRCC
rcQUlations and is certified to be operating within acceptable parameters_
�,... TYPE OF ASSEMBLY � 4
C � Reduced Pressure Principle � C pressure Va�'VL**n Breaker � `
.^-'� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer ', � Size � * --
Model Number
Serial Number
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Cetifi«i Testa
Cent. Testa No. Date
Whit¢ - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLTCJM BRFAT�R
Double Cheek Valve Assembly
Reiief Valve
Air Inlet
Check Valve
1st Checl:
2nd Cheel:
Initial Test
DC- Closed
Tight 63'
Closed Tight t3
Leaked o
Opened at
_DSid
Opened at
vsid
vsid
R.p- osid
��� p
Did not Opca o
Leaked �
Repairs
and
Matcials
Used i
h
z ,�
I i
y � r
�
s
.
Test ARrr
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
osid
Opined at
osid
osid
Rp sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Cetifi«i Testa
Cent. Testa No. Date
Whit¢ - Customer's Copy Yellow -City Copy Pink - Tester's Copy