2011_0725CIIECK ONE.
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IRRIGATION DOMESTIC �� F'IRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacutnn Breaker
Double Check Valve o Atmosphere Vacuum Breaker
�-
Manufactaffer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa .
Cert. Testa No. � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'�►T�R
Double Check Valve Assembly
1st Checl:
tad Checl:
Relief Valve
:fir Inlet
Cheek Valve
Initial Test
DC- Closed
Ti_ehL �
Closed Tight d
I -oakcd o
Opined at
osid
Opined at
nsid
nsid
RP- n51 i
Leaked �
Did not Opm o
Leaked �
RePai�-e
and
Materials
Used
Test ASa
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
osid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa .
Cert. Testa No. � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy