2011_1118CIIECH ONE=
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEI►�LY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacl.-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
reQUlauons and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Presstac Principle `" C � Pressure Vacuum Breaker
C� Double Check Valve o Atmosphere Vacuum Breaker
Manufactsser Size
Model Number
Serial Number
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
CeztiSed Tester
Cezt Tester No. Date
7LTM BRE_AT�R
Cheek val.•e
vsid
Leaked C
vsid
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Initial Test
DC- Closed
Tight CS
Closed Tight O
Leaked o
Opened at
vsid
Opined at
vsid
RP- vsid
��� p
Did not Opm o
�P�n
and
Materials
Used
Test Agar
Repair
DC- Closed
Tight �
Closed Tight o
Opened at
vsid
Opmod at
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
CeztiSed Tester
Cezt Tester No. Date
7LTM BRE_AT�R
Cheek val.•e
vsid
Leaked C
vsid
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy