2012_0927CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE e-�'�
BACKFI..OW PREVENTION ASSEA�LY TEST AND PriA.II�I'I'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. # _
LOCATION OF SERVICE:
The bacll�llow prevention assembly detailed below has been tested and =na;nrained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure VanSt^n Breaker
�" Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Ca-tified Tester
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B���R
Double Check Valve Assembly
Relief Valve
Air Inlet
Cheek Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tight C3'
Closed Tight �
Leaked o
Opened at
vsid
Opmcd at
vsid
vsid
Rp- vsid
��� p
Did not Opm o
Leaked �
Rcpa��s
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight 0
Closed Tight v
Opined at
vsid
Opined at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Iast accuracy tested
Ca-tified Tester
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy