2012_1130 (6)CHECK 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 bacl. -flow prevention assembly detailod below has bees tested and **+a�*+ta;ned as required by TNRCC
rcQUlations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacua*++ Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
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 Testa No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJLTM BRE_�►T�'R
Doubie Cheek Valve Assembly
Relief Valve
Air Inlet
Chec3c Valve
1st Check
2nd Cheek
Initial Test
DC- Closed
Tight �
Closed Tight C
Leaked C
Opined at
_vsid
Opened at
nsid
vsid
R.p- vsid
��� p
Did not Open o
Leaked '-�
Repairs
and
Materials
Used
Test ARa
Repair
DC- Closed
Tight a
Itp std
Closed Tight a
Opined at
vsid
Opened at
vsid
nsid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Testa No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy