2012_0608CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The back -low 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 ❑ Atmosphere Vacuum Breaker
Manufacturer 1 � n s
Model Number
Serial Number q; L/b -
Size
Located At L--U U r) d Y- y
The above is certified to be true.
Firm Name Certified Tester
Firm Address _ Cert. Testa No.
Gauge # c
Date last accuracy tested!
Date
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
:fir Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
nsid
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Ater
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address _ Cert. Testa No.
Gauge # c
Date last accuracy tested!
Date
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy