2012_0117 (17)CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: COr!�/r% . � • //� %f7L �k%�7G1�
The bacicflow prevmtioa assembly detailed below has bcea tested and maintained as required by TNRCC
rcgtrlations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
rn'� Double Check Valve o Atmosphere Vacuum Breaker
i
Manufactaa-er _ Size / � -
Model I�iumber - Located At %. , - =1 `_ �
Serial Number 1-
The above is certified to be rive.
Firm Natoe
Firm Address '"_
Gauge #
Date last accuracy tested
Certified Tester -
CerL Tester No. � � Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIJ'CTM BREAKER
Double Check Valve Assembly
1st Cheek
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
asid
TishL �
Leaked a
vsid
asid
!"
RP- vsid
__
i rued p
Did not Opm o
Leaked '�
Repairs
and
Mata-ials
Usod
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
asid
Repair
Tight �
asid
asid
RP sid
The above is certified to be rive.
Firm Natoe
Firm Address '"_
Gauge #
Date last accuracy tested
Certified Tester -
CerL Tester No. � � Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy