2012_1130CHECK ONE.
IRRIGATION
DOMESTIC
FIR ELIN E
BACKFLOW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF Pws: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has bem tested and maintained as required by TNRCC
reQUlations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuum Breaker
p Double Check Valve D AtmosphQe Vacuum Breaker
Manufaciaser
Model Number
Serial Number
Size
Located At
The above is cctified to be true.
Firm Name
i�iT.:.7i�L -�3
Gauge #
Date last accuracy tested
Certified Tests
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR_F'a►�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Chetl:
2nd Checi:
Initial Test
DC- Closed
Tight D
Closed Tight o
Leaked �
Opined at
nsid
Opined at
vsid
nsid
RP- nsid
��� p
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Agar
Repair
DC- Closed
Tight a
R.p sid
Closed Tight o
Opined at
nsid
Opined at
nsid
nsid
The above is cctified to be true.
Firm Name
i�iT.:.7i�L -�3
Gauge #
Date last accuracy tested
Certified Tests
Cert. Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy