2012_0810 (2)CHECK ONE:
DOMESTIC
IRRIGATION ®_� __ FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: XIL 1l ,
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 o Pressure Vacuum Breaker
o Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Scrial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested C.P ` � _../ aL
Certified Testa
Cert. Testa No. 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 o
Opened at
Dsid
Opened at
nSid
nSid
RP- ._psid
Leaked ❑
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
nSid
nsid
Ir
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested C.P ` � _../ aL
Certified Testa
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy