2013_0125CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE �j
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backflow 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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer W i J Size (� L
Model Number Located At
Scrial Number 0 0�
The above is certified to be true.
Firm Name
,, r r V, c e Vr-A ec� n. Inc - Certified Tester a
Firm Address ' I r ' Cert. Testa No. Date
Gauge #
Date last accuracy tested
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
Closed Tight ❑
Opened at
Opened at
nsid
A r �
Tight ❑
RP- :% > sid
Leaked ❑
Leaked ❑
osid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name
,, r r V, c e Vr-A ec� n. Inc - Certified Tester a
Firm Address ' I r ' Cert. Testa No. Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy