2012_1023CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: a '
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
reeUlanons and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size -
Model Number �° k Located At
Serial Number
Initial Test
16, S<>
Repairs
and
Materials
Used
Test After
Repair
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
Sid
Did not Open C1
oSid
Leaked C3
DC- Closed
Tight ❑
RP- __pSid
Leaked ❑
DC- Closed
Tight ❑
RP— sid
Closed Tight ❑
Opened at
vsid
Opened at
_ Sid
osid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy