2012_1130 (5)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bac3cflow prevmtioa assembly detailed below has bem tested and maintained as required by TNRCC
re¢uiations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pressure Principle a Pressure Vacuum Breaks
C Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
Modei Number
Scrim Number
Size
Located At
The above is certified to be true.
Firm Name
Gauge #
Date last accuracy tested
Certified Testa
Cat Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR�'.t�R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Cheek
2nd Cheek
Closed Tight �
Leaked o
Opened at
_acid
Opined at
nsid
nsid
Initial Test
DC- Closed
Tight C]
Rp- vsid
�� p
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight �
Rp std
Closed Tight o
Opined at
vsid
Opened at
vsid
nsid
The above is certified to be true.
Firm Name
Gauge #
Date last accuracy tested
Certified Testa
Cat Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy