2012_0117 (21)CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �� � _ � %J�G,if /Z��j�l�'
The bacicflow pmmtioa assembly detailed below has been tasted and maintained as required by TNRCC
re_Qtrlarions and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
e Reduced Pzcssurc Principle a Pressure Vactnmi Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number - Locatad At �
Serial Ntmzber -
The above is certified to be true.
Firm Name
Firm Address
Gauge # � -
Date last accuracy tested
Certified Tester
Ctrt. Tester No_
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFA►�'R
Double Check Valve Assembly
1st Check
tad Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight [3
Opened at
Opined at
vsid
Tight [y
Leaked o
vsid
vsid
RP- vsid
Lcaled a
Did not Opm D
Lcaled �
�P��
and
Mata-ials
Used
Test ARer
DC- Closed
Closed Tig. ht o
Opened at
Opined at
vsid
Repair
Tight �
nsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # � -
Date last accuracy tested
Certified Tester
Ctrt. Tester No_
Date
Wtute - Customer's Copy Yellow -City Copy Pink - Testers Copy