2012_1026CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE= !C� � � �.F- i�c�x�.,��c� --
The bacicflow prcvmtioa assembly detailed below has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacui***+ Breaker
_^_ Double Check Valve o AtmosphQe Vacuum Breaker
Maaufactauer �-- .''^ -�° `� Size �
Model Number � i �=> �� Located At
Serial Number I (nri / �>
The above is certified to be true.
Firm Name
Firm Address
Gauge �
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B���R
Double Check Valve Assembly
1st Check
tad Checl:
Relief Valve
Air Inlet
Chec3c Valve
Initial Test
DC- Closed
Tight �
Closed Tight o
Leaked ' o
Opeaed at
vsid
Opined at
vsid
vsid
RP- vsid
Leaked o
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Arta
Repair
DC- Closed
Tight �
Closed Tight t7
Opeaed at
vsid
Opined at
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge �
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy