2012_0927t
CIIECK ONE. `-
IRRIGATION `:
DOMESTIC
FIRELIN E
BACICF'LOW 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 been tested and maintained as required by TNRCC
reeulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vactn�**+ Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be uue.
Firm Name -
Firm Address
Gauge #
Date last accuracy tested -
Cctified Tester
Ceri. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM SR�'a.�R
Double Chec3c Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
?ad Cheri:
Initial Test
DC- Closed
Closed Tight C7
Opined at
Opined at
vsid
Ti_eht o
Leaked o
vsid
vsid
RP- vsid
��� p
Did not Open o
Leaked '�
RePa�r�
and
Materials
Used
Test Altar
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Rapair
Tight o
vsid
vsid
Rp sid
The above is certified to be uue.
Firm Name -
Firm Address
Gauge #
Date last accuracy tested -
Cctified Tester
Ceri. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy