2012_0117 (14)CHECK ONE:
IRRIGATION DOMESTIC __ FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: /��%�G%�K?flttrC
The bacl. -flow prevmtioa assembly detailed below has bem tested aad maintained as rec�ired by TNRCC
nEUlations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C _ Reduced Pressurc Principle C Pressure Va�-ut*•*_+ Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Nt�ber
Serial lvumber "`
Size
Located At
The above is rectified 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 - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT�'R
Double Chec3c Valve Assembly
1st Cheek
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight C-T
Closed Tight a
Leaked �
Opined at
vsid
Opined at
vsid
vsid
RP- vsid
Leaked p
Did not Opm o
Leaked �
Repaus
and
Materials
Used
Test Afi�r
Repair
DC- Closed
Tight �
Closed Tight o
Opcaed at
nsid
Opined at
osid
osid
RP std
The above is rectified 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 - Tester's Copy