2012_1221CHECK ONE.
IRRIGATION
DOMESTIC
FIRELIN
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D_ #
LOCATION OF SERVICE:
The bael�low prevention assembly detailed below has been tested and ma;nrained ag required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Presstac Principle a Pressure Vann_**+ Breaker
.^_ Double Check Valve � Atmosphere Vacuum Breaker
Manufact�ser
Modei Number
Serial Ntzmber
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No_
Date
Wtu.te - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF_AT�'R
Double Check Valve Assembly
1st Cheek
2nd Cbecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed -`�, - �=
Closed Tight o
Opened at
Opened at
nsid
Ti_aht Q
Leaked o
nsid
nsid
RP- nsid
Leaked [7
Did not Opm o
Leaked C7
RtPairc
and
Materials
used
Test ARer
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No_
Date
Wtu.te - Customer's Copy Yellow -City Copy Pink - Testers Copy