2012_1026CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACHYLOW 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
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Serial Number
Located At
The above is certified to be true.
Firm Name G
Firm Address
Gauge #
Date Last accuracy tested '
Certified Tester
Cert. Tester No. 00/-6—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
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
nsid
nSid
RP- pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nSid
nSid
RP sid
The above is certified to be true.
Firm Name G
Firm Address
Gauge #
Date Last accuracy tested '
Certified Tester
Cert. Tester No. 00/-6—Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy