2013_0725CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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
C Reduced Pressure Principle C Pressure Vacuum Breaker
^_ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number Located At
Serial Number
The above is certified to be true..,
Firm Name } "`
Firm Address
Gauge # I �
Date last accuracy tested
Certified Tester
Cat Testa 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 a
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
nsid
__ nsid
RP sid
The above is certified to be true..,
Firm Name } "`
Firm Address
Gauge # I �
Date last accuracy tested
Certified Tester
Cat Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy