2013_0612 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
Ui (\c
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 C Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufaciurcr (' K i n S Size
Model Number Located At
s
Serial Number
The above is certified to be true.
Firm Name
���` Certified Tester a `
.r ., ! Cat Testa No. �, -., U ! Date t r 1,
Firm Address
Gauge # _
Date last accuracy tested q _ 't.- 17
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
DSid
Opened at
oSid
oSid
RP- DSid
Leaked ❑
-r
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
oSid
oSid
RP sid
The above is certified to be true.
Firm Name
���` Certified Tester a `
.r ., ! Cat Testa No. �, -., U ! Date t r 1,
Firm Address
Gauge # _
Date last accuracy tested q _ 't.- 17
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy