2013_1216CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: < 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.
c
n
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
Serial Number "� o ) 5 (
TYPE OF ASSEMBLY
C, Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be =e...
Firm Name n
Firm Address 114 V h g 1 I) ) i
;,, -v
Gauge # 1 1 1
7UM BREAKER
Check Valve
nsid
Leaked O
nSid
j
Certified Tester 1/(
P
Cert. Tester No. Date_
Date last accuracy tested ' 2 J `
_- .-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V ACl
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight 0
Opened at
Opened at
Tight o
Leaked o
psid
nSid
RP- psid
Leaked o
Did not Open o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
Repair
Tight o
psid
nSid
RP sid
The above is certified to be =e...
Firm Name n
Firm Address 114 V h g 1 I) ) i
;,, -v
Gauge # 1 1 1
7UM BREAKER
Check Valve
nsid
Leaked O
nSid
j
Certified Tester 1/(
P
Cert. Tester No. Date_
Date last accuracy tested ' 2 J `
_- .-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy