2012_1030CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: K I A
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
c
n
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
." r-g--�77
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
L9 4
Gauge #
5
Date last accuracy tested
Certified Tester {� "r, P
Cat. Testa No. Dated Z
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 ❑
Closed Tight ❑
Leaked ❑
Opened at
vsid
Opened at
osid
osid
RP - psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
L9 4
Gauge #
5
Date last accuracy tested
Certified Tester {� "r, P
Cat. Testa No. Dated Z
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy