2013_0905 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ,A !? L
The back -low 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
Serial Number
Located At
The above is certified to be true.
Firm Name
Firm Address ����/�ir►'a/.�U��tt'
fX ]�
Gauge #
Date last accuracy tested .' �/'/ /'
Certified Tester �' l
Cert. Tessier 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
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
pSid
Opened at
nSid
nSid
RP- __,_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nSid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address ����/�ir►'a/.�U��tt'
fX ]�
Gauge #
Date last accuracy tested .' �/'/ /'
Certified Tester �' l
Cert. Tessier No. ` / Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy