2012_0523 (4)CHECK ONE=
IRRIGATION
DOMESTIC
FIRELINE
BACKFI,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. # _
LOCATION OF SERVICE:
The baci�Iow prevention assembly detailed below has bcm tested and maintained as regttir+cd by TNRCC
regulations and is ccrvified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vaetn**e+ Breaker
� Double Chxk Valve _ O Atmosphere Vacuum Breaker
Maaufact�aer
Model Ivumbcr
Serial Number
Size
Located At
The above is certified to be true_
Firm Name _
Firm Address
Gauge #
Date Iast accuracy tested
Certified Testa
Cent Testa No_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BI2FATt"FR
Double Cherlc Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight O
Opeaed at
Opeacd at
nsid
Tight �
Leaked o
vsid
nsid
RP- nsid
��� p
Did not Open o
Leaked '�
RcPa,r�
and
Mata-iais
Used
Test Auer
Repair
DC- Closed
Tight o
Closed Tight o
Opeaed at
nsid
Opined at
vsid
._.o.... ___ _
nsid
RP sid
The above is certified to be true_
Firm Name _
Firm Address
Gauge #
Date Iast accuracy tested
Certified Testa
Cent Testa No_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy