2012_0523 (2)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFT.,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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 C Pressure Vacutmm Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number Located At
Serial Nttmba �r�
The above is certified to be true.
Firm Name
E �r.-.7_�fr��
Gauge #
Date last accuracy tested
Certified Testa
Cat. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLTCTM B���R
Double Check Valve Assembly
1st Chec3:
tad Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tight o
Closed Tight -m
Leaked o
Opined at
nsid
Opined at
nsid
nsid
RP- vsid
Leaked o
Did not Opm o
Leaked o
�P��
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
nsid
_
Opined at
vsid
__
nsid
RP sid
The above is certified to be true.
Firm Name
E �r.-.7_�fr��
Gauge #
Date last accuracy tested
Certified Testa
Cat. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy