2012_1026CIIECK 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 baci�low prcvmtion assembly detailed below has bem'.usted aad 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
d Double Check Valve o Atmosphere Vacuum Breaker
Maaufacvaer �3��T7T�% ` Size
Model Number �1 � Located At
Serial Number � l
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
Certified Tester
CerL Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM SRFAitFR
Double Cheek Valve Assembly
1st Cheek
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight .1�3"
Opined at
Opined at
vsid
Tight C3"
Leaked o
nsid
nsid
RP- vsid
Leaky p
Did not Opm o
Leaked �
�P�s
and
Materials
Used
Test Auer
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight �
nsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
Certified Tester
CerL Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy