2012_0621CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW 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
c Reduced Pressure Principle ❑ Pressure Vacuum Breaker
'Se Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Scrial Number
size
Located At / /L
The above is certified to be true.
Firm Name Certified Tester /, /,
Firm Address i3o X y yam. Cert. Tester No. /���'��GUI Date
Gauge # .,o
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight 0
Leaked ❑
Opened at
vsid
Opened at
vsid
vsid
R.P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
vsid
Opened at
vsid
vsid
RP sid
The above is certified to be true.
Firm Name Certified Tester /, /,
Firm Address i3o X y yam. Cert. Tester No. /���'��GUI Date
Gauge # .,o
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy