2012_0117 (4)CHECK ONEc
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEA�LY TEST AND MAIi�T'TENANC� REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: / E70 �, i %�i4� i�� i Ali/
The bacicflow prevention assembly detailed below has bcm tested and maintained as required by TNRCC
regulations and is certified to be ope5ating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Va�-vL�*a Breaker
3" Double Check Valve C Atmosphere Vacuum Breaks
Manufacaaer Size
Model Number - Located At
Serial Number .' "_.�. �, _ _'
The above is certified to be trot.
Firm Name
Firm Addtzss
Gauge # -
Date last accuracy tested
Catafied Tester
Cest Testa No.' �" Dau
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR�'A�R
Double Cher3c Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
asid
Tis�t o
Leaked C
vsid
asid
RP- asid
Leaked p
Did not Opm o
Leaked o
�P��
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
asid
Repair
Tight o
Dsid
asid
RP sid
The above is certified to be trot.
Firm Name
Firm Addtzss
Gauge # -
Date last accuracy tested
Catafied Tester
Cest Testa No.' �" Dau
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy