2012_0927 (2)=.
CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEA'IBLY TEST AND MA.iIVPENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has bcm tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
o Reduced Pressure Principle a Pressure Vacuttm Breaker
�' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Model Iii umber
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Addrz�ss
Gauge #
Date last accuracy tested
Certified Tester
s_ �
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLTCTM BRFA�R
Double Check Valve Assembly
1st Check
and Chccl:
Relief Vaivc
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight �'
Closed Tight o -
Leaked o
Opined at
vsid
Opined at
vsid
vsid
RP- vsid
Leaked a
Did not Open o
Leaked '�
�P�n
and
Matcials
Used
Test Af%r
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight Q
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Addrz�ss
Gauge #
Date last accuracy tested
Certified Tester
s_ �
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy