2012_0117 (15)�. �
CIIECK ONE.
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I_D. #
LOCATION OF SERVICE:
The bacicIIow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacutmm Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Maaufactttrer Size
Model Number
Serial Number
Located AL
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
JLTM BREAT�R
Cheek Valve
nsid
Leaked a
nsid
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Initial Test
DC- Closed
Tight L7
Closed Tight C
Leaked o
Opened at
nsid
Opined at
nsid
RP- nsid
��� p
Did not Open o
Repairs
and
Mata-ials
Used
Test Agar
Repair
DC- Closed
Tight 0
Closed Tight o
Opined at
nsid
Opined at
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No.
Date
JLTM BREAT�R
Cheek Valve
nsid
Leaked a
nsid
White - Customer's Copy Yellow -City Copy Pink - Testers Copy