2013_1008CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAOCFLOW 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
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name `/ `I Certified Tester
Firm Address//() /�'r r t/9 Cert. Tester No. Date
Gauge # "' /640 1// f
Date last accuracy tested
TUM BREAKER
Check Valve
nsid
Leaked ❑
nsid
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
Tight ❑
Leaked ❑
nsid
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name `/ `I Certified Tester
Firm Address//() /�'r r t/9 Cert. Tester No. Date
Gauge # "' /640 1// f
Date last accuracy tested
TUM BREAKER
Check Valve
nsid
Leaked ❑
nsid
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy