2012_0702CHECK ONE.
IRRIGATION
DOMESTIC
FIRELIN
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE
The barlcflow prcvmtion assembly detailed below has bem tested and maintained as requirzd by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Rcduccd Pressure Principle C Pressarrc Va�-uL�*n Breaker
Double Check Valve D Atmosphere Vacuum Breaker
Manufactrner __ Size -
Model Number Located At
Serial Number f - J
The above is certified to be trot.
Firm Name -= f _
Firm Address /: -/�
Gauge # O� v y 2 ` �3-
Date last accuracy tested � - 5 - / 2--
Certified Tester
Cert. Tester No. -� Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1rIBLY
PRESSURE VACUUM SRFAKF'It
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight lq
Opened at
Opined at
nsid
- -
Tight 1dJ
Leaked �
nsid
nsid
RP- vsid
Leaked a
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Alter
DC- Closed
Closed Tight o
Opined at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be trot.
Firm Name -= f _
Firm Address /: -/�
Gauge # O� v y 2 ` �3-
Date last accuracy tested � - 5 - / 2--
Certified Tester
Cert. Tester No. -� Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy