2012_1210CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAI2�TI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D_ #
LOCATION OF SERVICE:
The bacicflow przvmtion assambly detailed below has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle c Pressure Vacutmm Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Maaufachtrer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
Wtate - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BFLEAE�R
Double Cheek Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Tis=ht o
Leaked o
nsid
vsid
RP- nsid
�� p
Did not Opm o
Leaked �
�P�n
and
Materials
Used
Test ARrr
DC- Closed
Closed Tig. ht o
Opened at
Opmod at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
Wtate - Customer's Copy Yellow -City Copy Pink - Tester's Copy