2012_1031CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: Par- ) tM1 ,
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
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer /r�Su Size
Model Number d Located At
Serial Number 3
The above is certified to be true.
Firm Name Certified Tester
Firm Address
Gauge #
Date last accuracy tested
Cat. Tester 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
:fir Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
nsid
nsid
RP- _,psid
Leaked C
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight C
Opened at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address
Gauge #
Date last accuracy tested
Cat. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy