2013_0426CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bac0ow 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 12 Pressure Vacuum Breaker
❑ Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer L el Size
r;
Model Number 45U S (� Located At
Serial Number
The above is certified to be true.
i
Gauge # / 1 0 % Q q O"-f
Date last accuracy tested 2 - -/
Certified Tester /—
f /
Cert. Tester No. -3 Z! 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 : l
Tight
Closed Tight ❑
Leaked ❑
Opened at
Dsid
Opened at
nsid
nsid
RP- psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight
Closed Tight o
Opened at
psid
Opened at
vsid
nsid
RP sid
The above is certified to be true.
i
Gauge # / 1 0 % Q q O"-f
Date last accuracy tested 2 - -/
Certified Tester /—
f /
Cert. Tester No. -3 Z! Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy