2012_0608 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRE]LINE
BACKFLOW PREVENTION ASSEMBLE' TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer / A! N �.� it
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size -� C-
Located At i, -) d
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
1. - . .
Cert. Testa No. I Date
TUM BREAKER
Check Valve
oSid
Leaked ❑
sid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
cj
Tight ❑
RP -_ —psid
Leaked ❑
Leaked ❑
psid
oSid
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
Sid
Sid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
1. - . .
Cert. Testa No. I Date
TUM BREAKER
Check Valve
oSid
Leaked ❑
sid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy