2012_1029CIIECK ONE=
IRRIGATION _ - -
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
�J ��/^� �
LOCATION OF SERVICE: / �./� -�' i �( Yl � � G i�' _}
The bacicflow prevention assembly detailed below has been tested aad maintained as required by TNRCC
reQUlauons aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacua**+ Breaker
3 Double Chxk VaIvc O Atmosphere Vacuum Breaker
Manufacttaer Size
Model Number _
Serial Number �
Located At
The above is certified to be true.
Firm Name
Firm Address _
Gauge #
Date Iasi a��ura�y testes _
Certified Tester
Cert. Tester No. : � ( Date ��
Wtute — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'AT�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Cheep
2nd Checi:
Initial Test
DC- Closed
Tight; �(
Closed Tight o "
Leaked D
Opined at
vsid
Opmcd at
osid
vsid
R.p- � i vsid
��� p
�
Did not Opm o
Leaked C
�P�
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight 0
Closed Tight �
Opened at
vsid
Opeaed at
vsid
osid
Rp sid
The above is certified to be true.
Firm Name
Firm Address _
Gauge #
Date Iasi a��ura�y testes _
Certified Tester
Cert. Tester No. : � ( Date ��
Wtute — Customer's Copy Yellow —City Copy Pink — Tester's Copy