2012_1130CHECK ONE=
IRRIGATION DOMESTIC P'IREI,LN
BACTCFI.OW PREVEN'T'ION ASSElO�LY TEST AN1D 7VL4lIN'T'LPdANC;E REPORT
NAME OF PWS: CITY OF COPPELL _
PWS I_D. # _
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
rc2ulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C I2cduc.�d Pressure Principle C Pressure Va�-tr�***+ $t=aker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacttser Sizc
Model Number � � Located At
Serial Number �� ` � �
The above is certified to be trot_
Firm Name
Firm Addres_t
Gauge #
Illate last accuracy tested
Certified Tester
Cezt Tester No_
Date
W=rite — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSIJRE PRINCIPLE ASSEI��LY
PRESSUi2E VACUUM BRFal~�R
Double Check Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Ant Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight [7
Opened at
Opened at
nsid
Tight �
Lcakcd �
nsid
osid
RP- nsid
I.cal:cd p
Did not Open O
Leaked �
�P arts
and
Materials
used
Tcsi Afirr
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tight O
DSid
osid
RP sid
The above is certified to be trot_
Firm Name
Firm Addres_t
Gauge #
Illate last accuracy tested
Certified Tester
Cezt Tester No_
Date
W=rite — Customer's Copy Yellow —City Copy Pink — Tester's Copy