2012_0927CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAOULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: k �y�, r
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number V.
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa 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 ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
psid
psid
It -_nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
psid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy