2013_1015CHECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY 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 heck Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size
Located At
The above is cnti6ed to be true.
Firm N Certified Tester
Firm Address Cert. Tester No. �' ' __�llDate 1 l
Gauge # I
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
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed ,
Tight
RP -_psid
Leaked ❑
Closed Tight
Leaked � ❑
f
Opened at
nsid
Opened at
nsid
Did not Open ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed not ❑
Opened at
nsid
Opened at
nsid
_nsid
RP sid
The above is cnti6ed to be true.
Firm N Certified Tester
Firm Address Cert. Tester No. �' ' __�llDate 1 l
Gauge # I
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy