2012_0525CIIECK ONE.
IRRIGATION
DOMESTIC / � FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. # _ __
LOCATION OF SERVICE= :��f�», ���� �� -G�' /.��� /� %� �c /�
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 Press�c Principle Lam- Pressure Vacui+*n Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Natmber
- Size
Located At
The above is certified to be true.
Firm Name Certified Tester ; .� ` - --
Firm Address Cat Testa No. Date =-_
Gauge �
Dat¢ last accuracy tested
Wtute - Customer's Copy Yellow -City Copy Pink - Test¢r's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR>c'aT�'R
Double Check Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight C7
Closed Tight o
Leaked o
Opined at
vsid
Opined at
vsid
vsid
RP- vsid
��� p
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test ARcr
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
vsid
Opened at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name Certified Tester ; .� ` - --
Firm Address Cat Testa No. Date =-_
Gauge �
Dat¢ last accuracy tested
Wtute - Customer's Copy Yellow -City Copy Pink - Test¢r's Copy