2012_1012 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
r Pfn j i
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number C
Serial Number 16 mkt- - (�
Size
Located At
The above is certified to be true.
5 f
Firm Name G Certified Tester
Firm Address r lnlOG� a K l_ I Ic )Utm Tester No. i �G f � _ Date a�
Gauge Il O cj 0
Date last accuracy tested -
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
vsid
Tight ❑
Leaked ❑
Dsid
vsid
RP- __psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
nsid
Dsid
RP sid
The above is certified to be true.
5 f
Firm Name G Certified Tester
Firm Address r lnlOG� a K l_ I Ic )Utm Tester No. i �G f � _ Date a�
Gauge Il O cj 0
Date last accuracy tested -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy