2012_1011CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
j y - r
The baciflow 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 a Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
0j UR ID
Serial Number
Reps
and
Materials
Used
Test After DC- Closed Closed Tight C3 Opened at Opened at psid psid
Repair Tight
❑ _ vsid
RP sid
The above is certified to be true.
, Certified Testa
L
Firm Name �
Test
=1� t. a No.
-` ". . _ '.'�" Date
Firm Address Cer
� ' � ° 1 �.•
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Check 2nd Check Relief Valve
Air Inlet Check Valve
DC- Closed Closed Tight :3 Opened at
Tight ❑ Leaked ❑ psid
RP- ._psid
Leaked ❑
Opened at psid
ysid
Did not Open ❑ Leaked ❑
Initial Test
r�5 5
�!_ 1
Reps
and
Materials
Used
Test After DC- Closed Closed Tight C3 Opened at Opened at psid psid
Repair Tight
❑ _ vsid
RP sid
The above is certified to be true.
, Certified Testa
L
Firm Name �
Test
=1� t. a No.
-` ". . _ '.'�" Date
Firm Address Cer
� ' � ° 1 �.•
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy