2013_0822 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACMOW 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 z Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
-3 -0 z r c
Model Number
Serial Number
Located At
The above is certified to be true.
Firm Name
Firm Address 4",O
Gauge #
Date last accuracy tested
Certified Tester /41
Cat Tester No. f/' 7 J0,4A 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
Closed Tight ❑
Opened at
Opened at
osid
-7,?-t3
p�t5�®
Tight ❑
R� - __3,± Dsid
Leaked ❑
Leaked ❑
psid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address 4",O
Gauge #
Date last accuracy tested
Certified Tester /41
Cat Tester No. f/' 7 J0,4A Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy