2013_0204CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baclflow 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 C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name Certified Tester 4. "1
Firm Address r.,_ �6a y y Cert Tessler No.!'#'�o i �S I Date a - -3
Gauge # ) (n l
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
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tight ❑
Closed Tight in
Leaked ❑
Opened at
osid
Opened at
osid
osid
RP- ._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name Certified Tester 4. "1
Firm Address r.,_ �6a y y Cert Tessler No.!'#'�o i �S I Date a - -3
Gauge # ) (n l
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy