2013_0905CHECK 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
^_ Double Check Valve G Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Serial Number f > f /I
Located At
The above is certified to be true.
Firm Name t eu CaJyi.
Firm Address ' " /zG7 C- srar>ci�iir°
Gauge # 1:
Certified Tester
Cert. Tester No.9/0Or7'7:Q (o CJ Date
Date last accuracy tested
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy
0
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
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.
Firm Name t eu CaJyi.
Firm Address ' " /zG7 C- srar>ci�iir°
Gauge # 1:
Certified Tester
Cert. Tester No.9/0Or7'7:Q (o CJ Date
Date last accuracy tested
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy
0