2011_0812CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MA.IN'TENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD_ # -
LOCATION OF SERVICE: .:»� � �` S � � o � ��
The bacicflow prcvmtion assembly detailed below has bcea tested and maintained as required by TNRCC
regularions and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacui� Brraker
� Double�Chccic Valve � Atmosphere Vacuum Sneaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name _
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
Wtute — Customer's Copy Yellow —City Copy Pir�lc — Tester's Copy
ry
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR�'A�'R
Double Check Valve Assembly
1st Check
tad Checl:
Relief Valve
:fir Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opined at
Opined at
osid
Tight o
Leaked 0
osid
osid
RP- osid
I,caled p
Did not Opm o
Leaked '�
Repaus
and
Materials
Used
Test After
DC- Closed
Closed Tig. ht a
Opined at
Opined at
osid
Repair
Tight Q
osid
osid
RP aid
The above is certified to be true.
Firm Name _
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
Wtute — Customer's Copy Yellow —City Copy Pir�lc — Tester's Copy
ry