2013_0513CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # t f
LOCATION OF SERVICE:
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be opera ting within acceptable parameters.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number 0
..tip
Scrial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size s
Located At
The above is certified to be true.
Firm Name
Firm Address
i1
Certified Tester r`
Cert. Tester No. ? ' Date
Gauge # U a lJ 0'-1` 1
Date last accuracy tested
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
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
X
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
i1
Certified Tester r`
Cert. Tester No. ? ' Date
Gauge # U a lJ 0'-1` 1
Date last accuracy tested
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy