2012_0621 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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 ❑ Pressure Vacuum Breaker
^_ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Scrial Number
Located At
? X00,41
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent 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
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
Dsid
Opened at
nSid
nSid
RP -_ pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nSid
nSid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy