2011_1209 (2)CIIECK ONE.
LRRIGATION
DOMESTIC
FIRELINE �,/�
BACI�T.OW PREVENTION ASSEA�LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The baci�low prevention assembly detailed below has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Rcduccd Pressure Principle C Pressure Va�-uL�*n Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number -
Size
Located At
The above is certified to be brae.
Fitm Name
Ftfri;'z'
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY
PRESSiTRE VACUUM BRFAK�'R
Double Cheek Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight - ❑ �
Closed Tight ❑ "
I -caked o
.Opined at
nsid
Opened at
nsid
nsid
RP- nsid
Leaked �
Did not Opm D
Leaked '�
Repairs
and
MatrriaLs
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opined at
nsid
Opined at
vsid
nsid
RP sid
The above is certified to be brae.
Fitm Name
Ftfri;'z'
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy