2012_0810CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACICMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: tI 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.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacu= Breaker
❑ Double Check Valve G Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
From Address
Certified Tester
Cert. Tester No.
Gauge #
Date last accuracy tested
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
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
nsid
Opened at
nsid
nsid
RP- _psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
From Address
Certified Tester
Cert. Tester No.
Gauge #
Date last accuracy tested
Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy