2011_1118 (2)CHECK ONE:
LRRIGATIO N DOMESTIC FIRELIN E
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The bacicIIow prcvmtion assembly detailed below has berg tested aad maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle c Presstae Vacuwn Breaker
� Double Check Valve o Atmosphere Vacuum Btzaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Film Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No.
_ Dau %�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT�R
Double Check Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve
Air Itzlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight �
Leaked o
Opened at
vsid
Opened at
osid
vsid
RP- vsid
�� p
Did not Opm D
Leaked �
Repairs
and
Materials
_
Used
-
Test ARa
Repair
DC- Closed
Tigltt o
Closed Tight o
Opined at
vsid
Opened at
vsid
osid
RP sid
The above is certified to be true.
Film Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No.
_ Dau %�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy