2012_1025CHECK ONE:
IRRIGATION DOMESTIC FIR ELIN E
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAII�TI'ENANC� REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: .��i�) �;� ( � �c�.✓ / � , ��
The bacictlow prevmtioa assembly detailed below has bees tested and maintained as req�red by TNRCC
rcgulacions sad is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle c Pressure Vacut� Breaker
�' Double Check Valve D Atmosphere Vacuum Breaker
ManufacLZrrer ��"Y� "�' � Size ��
Model Number � t°}l�� � Located At - ,' x� , `� -
,:
Serial Number ��S �� �� ��
The above is certified to be true. ,
Firm Name - Certified Testa �.s- �' �.
Firm Address -- Cat Trster No_ - Date - -
Gauge # -
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BR>G'A►�R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight e�"
Opined at
Opened at
osid
Tight ®'
Leaked �
osid
osid
RP- osid
Leaked a
Did not Opm o
Leaked �
Repairs
and
Materials
used
Test Ai%r
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight �
osid
nsid
RP sid
The above is certified to be true. ,
Firm Name - Certified Testa �.s- �' �.
Firm Address -- Cat Trster No_ - Date - -
Gauge # -
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Testers Copy