2012_1130 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE 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 requirzd by TNRCC
rcgulation5 and 15 certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c Rcduccd Pressure Principic a Fressurc Vacuum Breaker
� -� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Modci IV umber
Serial Number
Size
Located At
The above is certified to be true.
Firm Name ��+ yu h �_ �
Firm Address'.' 3� 1
Gauge # � t � -?t_� ��
Date last accuracy tested
Certified Tester
CerL Tester No_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'AT�R
Double Cheek Valve Assembly
1st Check
tad Chccl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight �'
Opened at
Opined at
nsid
Tight a-
`Leaked 0
nsid
nsid
R.P- nsid
I.ealed p
Did not Open o
Leaked �
�P�s
and
Materials
Used
Test Ages
DC- Closed
Closed Tight v
Opined at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name ��+ yu h �_ �
Firm Address'.' 3� 1
Gauge # � t � -?t_� ��
Date last accuracy tested
Certified Tester
CerL Tester No_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy