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CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
f. fi,
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
M Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer %f * ?414-J,
Size
Model Number , / Located At
Serial Number
/Y�-
/,%A(,", /, c;�;
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
White — Customer's Copy
Certified Testa
Cent. Testa No. Date
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
osid
osid
RP -_ psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
White — Customer's Copy
Certified Testa
Cent. Testa No. Date
Yellow — City Copy
Pink - Tester's Copy