2013_0509CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ; 1 l'� I
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 oxt�
Model Number
Serial Number 14 5 ! (P 0 5
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
1
Firm Name
Firm Address
Gauge # D
Date last accuracy tested �! -
i
Certified Tester
Cert. Tester No. 3Date '5/9 Ili
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- Closcd
Closed Tight W
Opened at
Opened at
osid
Tight ❑
Leaked ❑
osid
osid
RP- _psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
1
Firm Name
Firm Address
Gauge # D
Date last accuracy tested �! -
i
Certified Tester
Cert. Tester No. 3Date '5/9 Ili
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy