2012_0608CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL,
PWS I_D. #
LOCATION OF SERVICE:
The bacieflow prevention assembly derailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLX
e Reduced Pressure Principle � e pressure Vaculnn Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer S17e
Model Number Located At
Serial Number ' - s `
The above is certified to be true.
Firm Name
Firm Address
Gauge #
L7ate last accuracy tested
Certified Testa
Cert. Testa No. Dau
White - Customer's Copy Yellow -City Copy Pirilc - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1bIBLY
PRESSURE VACi.TiJM BR1FA�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
TiehL e"
Closed Tight -2]-
Leaked o
Opined at
osid
Opined at
osid
osid
RP- osid
��� p
-.
Did not Opea o
Leaked �
Repaus
and
Materials -
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opmcd at
osid
Opened at
osid
DSld
RP std
The above is certified to be true.
Firm Name
Firm Address
Gauge #
L7ate last accuracy tested
Certified Testa
Cert. Testa No. Dau
White - Customer's Copy Yellow -City Copy Pirilc - Tester's Copy