2012_0709CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer G-
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true. n
Firm Name
/)A-dr4 0 )a Certified Tester ' Apo
Firm Address 3 q 61 i!� q Cert. Tester No.4 #000� sS e Date �-
Gauge # 7-
Date last accuracy tested
12— +( f— (/
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
Tigh5 ❑
RP-_j. sid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
nsid
Opened at
nsid
Did not Open ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
nsid
nsid
RP sid
The above is certified to be true. n
Firm Name
/)A-dr4 0 )a Certified Tester ' Apo
Firm Address 3 q 61 i!� q Cert. Tester No.4 #000� sS e Date �-
Gauge # 7-
Date last accuracy tested
12— +( f— (/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy