2012_1029 (3)CIIECK ONE.
IRRIGATION DOMESTIC
FIR ELINE
BACKFT.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: % `- >,'
The bacicflow prevention assembly derailed below has been 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 Vacuum Breaker
G� Double Check Valve � Atmosphere Vacuum Breaker
Maaufacttu-er
Modes Number
Serial Number
Size
Located At
t
The above is certified to be true.
Firm Name
Firm Address
Gauge # -
Date last accuracy tested
Certified Testa
Cent Tester No_ � Date (O� "l �-
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Cheese
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight o
Closed Tighe o
Leaked o
Opened at
nsid
Opened at
nsid
nsid
RP- nsid
��� p
Did not Opm o
Leaked �
�P�
and
Materials
Used
Test After
I2cpair
DC- Closed
Tight o
Closed Tight o
Opined at
nsid
Opined at
nsid
nsid
R.P sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # -
Date last accuracy tested
Certified Testa
Cent Tester No_ � Date (O� "l �-
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy