2013_0522 (2)CHECK 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.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
5y Double Check Valve C7 Atmosphere Vacuum Breaker
Manufacturer ��S Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name Qyn P Certified Tester !) , irro� t (�.
Firm Address G101 55 Cent. Testa No. P► 2 1 Date f 3
Gauge # 09 () 9m 0
Date last accuracy tested —9
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
--psid
Tight ❑
Leaked ❑
psid
vSid
R.P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name Qyn P Certified Tester !) , irro� t (�.
Firm Address G101 55 Cent. Testa No. P► 2 1 Date f 3
Gauge # 09 () 9m 0
Date last accuracy tested —9
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy