2013_1220CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:'`
The bad. -Dow 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
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number /` ! / �D L�49
The above is certified to be true.
Firm Name Certified Tester
Firm Address / ✓ /1, Cert. Tester No. Date
C
Gauge # U 1 iC
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
1st Cheri:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
-Opened at
Opened at
oSid
Tight ❑
Leaked ❑
nsid
oSid
RP - ... psid
Leaked ❑
Did not Open D
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
oSid
oSid
RP Sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address / ✓ /1, Cert. Tester No. Date
C
Gauge # U 1 iC
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy