2012_0910 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: S_ \
The bacifflow 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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number At
Serial Number ... ®� Z..
The above is certified to be true.
Firm Name'~t
Firm Address ' 1
Gauge #
s.l..._ Certified Testa
Cat. Testa No. ` __ _ Date
Date last accuracy tested a" /,—A � .
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
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
oSid
oSid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Name'~t
Firm Address ' 1
Gauge #
s.l..._ Certified Testa
Cat. Testa No. ` __ _ Date
Date last accuracy tested a" /,—A � .
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy