2011_1118 (4)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACICfi3.OW PREVENTION ASSENIBL.Y TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D_ #
LOCATION OF SERVICE:
The bacl�low prcvmtion assembly detailed below has bem tested aad mainta' red as required b.+ TNRCC
rcgttlations and is certified to be operating within acceptable pa:amcras_
TYPE OF ASSELY
e Reduced Pressture Principle C Pressure Vacutttn Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Mavufacttaer Size
Model Number
Serial Number
Located At
'
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR�'AT�R
Double Check Valve Assembly
1st Check
tad Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight Q
Opined at
Opined at
nsid
Tight o
Leaked O
nsid
nsid
RP- vsid
��� p
Did noc Opm o
Leaked '.�
Repatts
and
Materials
Used
Test Alter
Repair
DC- Closed
Tight Q
Closed Tight o
Opined at
vsid
Opined at
vsid
nsid
RP sid
The above is certified to be true_
Firm Name _
Firm Address
Gauge �
Date last accuracy tested
Certified Testa
Cent. Tester No. ' Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy