2012_1030CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVEN'T'ION ASSEI��LY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE:
The baei�low prevention assembly detailed below has been tested and maintained as required by TNRCC
rcQUiations and is ccrafied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacu�mm Breaker
� Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer
Modes Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Names
Firm Address _
Gauge #
llate last accuracy tested
Certified Tester
Cent Testa No. D�
White — Customer's Copy Yellow —City Copy Pink — Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaT�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Cheek Valve
1st Check
2nd Chetl:
Initial Test
DC- Closed
Tighe o
Closed Tight d
Leaked o
Opined at
nsid
Opined at
nsid
nsid
RP- nsid
��� p
Did not Opm o
Leaked �
�Pa�
and
Materials
Used
Test Ai%er
Repair
DC- Closed
Tight 0
Closed Tight o
Opined at
vsid
Opined at
vsid
nsid
gp sid
The above is certified to be true.
Firm Names
Firm Address _
Gauge #
llate last accuracy tested
Certified Tester
Cent Testa No. D�
White — Customer's Copy Yellow —City Copy Pink — Testers Copy