2012_0608CIIECK ONE=
IRRIGATION
DOMESTIC
FIRELINE
BACKF'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD_ #
LOCATION OF SERVICE: � � �I i r? � I �"["� Y� � :UCt �[
The bacicflow prcvmtion assembly detailed below has bem tested and maintained as required by TNRCC
rogttlations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLX
e Reduced Pressure Principle C pressure Vacurmm Breaker'
� Double Check Valve o Atmosphere Vacuum Breaker
Maaufacturer Size
`-
Modes N�ber Located At � ," -
Serial Number ��
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No:
Date
TUM BuFasr�'R
Check Valve
osid
Leaked �
osid
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE pRINC'IPLE ASSEMBLY
PRESSURE VACI
Double Cheese Valve Assembly
1st Check
tad Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight G3'
Opened at
Opined at
Tight @ �
Leaked o
..osid
osid
RP- osid
Leaked p
Did not Opm o
�P�,r`
and
Materials
f .
Used
Test Agar
DC- Closed
Closed Tight o
Opined at
Opined at
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No:
Date
TUM BuFasr�'R
Check Valve
osid
Leaked �
osid
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy