2012_0117 (5).�� 1.�[a3;Z�� �IL�F
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVEN'T'ION ASSEA�LY TEST AND MAT1�1T'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D- #
LOCATION OF SERVICE: � �'D > - ,��/�Gi�K� %IGI�
The bacl�low prevention assembly detailed below has bcm tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Ptassurc Principle C Pressure Va�-crL*+*+ Breaker
C' Double Check Valve C Atmosphere Vacuum Breaker
Manufactrtrer Size �
Model Number _ Located At - -
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Ce:ified Testa
Cat. Testa No_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'AI�R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight D
Closed Tight o
Leaked o
Opined at
osid
Opened at
osid
osid
izP- osid
��� C
Did not Opm o
Leaked C
�P�
and
Materials
Used
Test Af%r
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
osid
Opined at
osid
osid
ItP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Ce:ified Testa
Cat. Testa No_ Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy