2013_1008 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXFLOW 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
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Serial Number
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cat. Testa No. Date
TUM BREAKER
Check Valve
osid
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
Ininal Test
DC- Closed(
Tight V,
Closed Tight /6,
Leaked ❑
Opened at
osid
Opened at
osid
RP- .__psid
Leaked ❑
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Tester
Cat. Testa No. Date
TUM BREAKER
Check Valve
osid
Leaked ❑
nsid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy