2012_0126CHECK ONE.
IRRIGATION � DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAII�iT'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE: a - %C:(lc lJi�
The bacl. -flow pn_wmtion assembly detailed below has been tested and main a;*,ed as required by TNRCC
reguiations aad is ca-tificd to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c Reduced Pressure Principle a Pressure Vacuum Breaker
. Double Check Valve O Atmosphere Vacuum Straker
Maaufacnaer
Modei Number
Serial Nimmber
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cent Testa No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFZF'AT�'R
Double Check Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opened at
Opened at
osid
Tight o
Leaked �
nsid
osid
RP- osid
waked p
Did not Open O
Leaked �
Repairs
and
Mata-ials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cent Testa No. Date
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy