2012_0926CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACEILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
D Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number`
Size
Located At
The above is certified to be true.
Firm Name 'a Certified Tester
.� I j' --.-.. ,'",� Cert. Tests No.i'��i / S Date
Firm Address
Gauge #
Date last accuracy tested
P', RA C-6
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Che:6
2nd Check
Initial Test
DC- Closed
Tight ❑
R.p - 19�0 psid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
vsid
Opened at
Sid
Did not Open ❑
oSid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Rp sid
Closed Tight ❑
Opened at
osid
Opened at
oSid
osid
The above is certified to be true.
Firm Name 'a Certified Tester
.� I j' --.-.. ,'",� Cert. Tests No.i'��i / S Date
Firm Address
Gauge #
Date last accuracy tested
P', RA C-6
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy