2012_0525 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACKFi..OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: /GiS� t /y- / / /��� /�� 71��G ��.�r - / /T�-
The bacicflow prevention assembly detailed below has bcea tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle � Pressure Vacutnn Breaker
.^� Double Check Valve � Atmosphere Vacuum Breaker
Maaufacntrer ,' Size
Model Number
Serial Number
Located At i "� ;:
The above is certified to be true.
Fitm Name Certified Testa
Firm Addrzs_S � � Cent Testa No. - Dau
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAG'IJ'CTM BRF�*T�'R
Double Check Valve Assembly
1st Cheek
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight o
Closed Tight o
Leaked �
Opined at
vsid
Opined at
vsid
vsid
RP- vsid
��� p
Did not Opm O
Leaked '.�
RePairc
and
Materials
Used
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
vsid
Opined at
vsid
nsid
RP sid
The above is certified to be true.
Fitm Name Certified Testa
Firm Addrzs_S � � Cent Testa No. - Dau
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy