2013_1122CIIECK ONE:
IRRIGATION
FIRELINE
BACKnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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
C Reduced Pressure Principle ❑ 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 r „
Firm Address
Gauge # 03 jw I/,(/,
Date last accuracy tested
Certified Testa
Cat. Tester No. 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
Closed Tight m -
--OMed at
Opened at
osid
Tight ❑
Leaked ❑
osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
p sid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name r „
Firm Address
Gauge # 03 jw I/,(/,
Date last accuracy tested
Certified Testa
Cat. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy