2013_1023CHECK ONE:
IRRIGATION
DOMESTIC
POP go 0
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The baclflow 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
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number yo' Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
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 o
Closed Tight o
Leaked 0
Opened at
nsid
Opened at
osid
osid
It -_psid
Leaked C
Did not Open o
Leaked O
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight a
Opened at
psid
Opened at
osid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
Certified Testa
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy