2012_1025CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEII�LY TEST AND M.A.IIV'I'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The baci�low prcvmtioa assembly detailed below has bem 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 Va�-uLn*+ Breaks
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be truce.
Firm Name
E;�rTT _r. r-r
Gauge #
Date last accuracy tested
Certified Tester
Cent. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEl►3BLY
PRESSURE VACUUM BIZFA�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Checl:
tad Cheer:
Ininal Test
DC- Closed
Tight o
Closed Tight �
Leaked �T"
Opined at
vsid
Opened at
nsid
nsid
'
RP- nsid
�� �
Did not Opm D
Leaked �
�P�
and
Mata-ials
Used
Test ARrr
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
vsid
Opined at
nsid
nsid
Rp sid
The above is certified to be truce.
Firm Name
E;�rTT _r. r-r
Gauge #
Date last accuracy tested
Certified Tester
Cent. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy