2012_0709 (2)CIIECK ONE:
IRRIGATION DOMESTIC____ FIRELINE
BACKFI.OW PREVENTION ASSEA�LY TEST AND MAIt�ITENANC'E REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The bacicflow prcvmtion assembly detailed below has bem tested and maintained as tzquizcd by TNRCC
rc¢ulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressttrc Vactn�**+ Breaker
r3 Doubic Check Valve D Atmosphere Vacuum Breaker
Maaufactttrcr
Model Number
Serial N�ba
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR�'AT�R
Double Cheek Valve Assembly
1st Check
tad Chekl:
Relief Valve
Air Idet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
TiahL CJ
Leaked O
vsid
osid
RP- osid
�� p
Did not Opm o
Lcal:cd �
RePa „-�
and
Materials
Used
Test Afia
Repair
DC- Closed
Tight �
Closed Tight D
Opined at
vsid
Opcaed at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy