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2012_0209CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY C Reduced Pressure Principle ❑ Pressure Vacuum Breaker ❑ Double Check Valve C Atmosphere Vacuum Breaker Manufacturers Size Model Number © Located At V L` Serial Number 'i c t - . The above is certified to be true. Firm Name ti, kA 4r-J -,) 1 Firm Address 4( Certified Tester f `° Cert Tester No.`s' Date `% Gauge # Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly 1st Check: 2nd Check: Relief Valve I Air Inlet Check Valve Initial Test DC- Closed Tight ❑ Closed Tight ❑ Leaked ❑ Opened at Dsid Opened at osid osid RP -_psid Leaked ❑ Did not Open ❑ Leaked ❑ Reps and Materials Used Test After Repair DC- Closed Tight Cl Closed Tight C Opened at osid Opened at osid osid RP sid The above is certified to be true. Firm Name ti, kA 4r-J -,) 1 Firm Address 4( Certified Tester f `° Cert Tester No.`s' Date `% Gauge # Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy