2012_0608 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACI{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #f
LOCATION OF SERVICE:
The bacldlow 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 C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer o �-� Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested ' `a
Certified Tester
Cent. Tester No. 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
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight C
RP- pSid
Leafed ❑
Closed Tight ❑
Leaked ❑
g
Opened at
_psid
Opened at
pSid
Did not Open ❑
nSid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight Cl
Opened at
oSid
Opened at
nSid
nSid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested ' `a
Certified Tester
Cent. Tester No. Date
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy