2012_1026CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �� � c ����� -��- �
The bacicflow prevmtloa assembly detailed below has beta tested aad maintained as required by TNRCC
reeulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
� Double Check Valve
Manufacturer � Zi`� �
Model Number
Serial Number ���-
TYPE OF ASSEMBLY
C Pressure Vaeanms Breaker
a Atmosphere Vacuum Breaker
Size
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_Ar�'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Cheek
Initial Test
DC- Closed
Tight �
Closed Tight d
Leaked - o
Opined at
vsid
Opined at
nsid
nsid
Rp- vsid
��� p
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Af%r
Repair
DC- Closed
Tigltt �
Closed Tight v
Opined at
nsid
Opined at
nsid
nsid
Rp sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Testers Copy