2013_1217CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACK MOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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
e Reduced Pressure Principle 12 Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name f /Si�E'rY "� Certified Tester
Firm Address ' � vuJ v ` f Cent Tester No.,-419M 0 4 W y Date d =�
Gauge # L
Date last accuracy tested
t .
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
Tight ❑
Leaked ❑
osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__ psid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name f /Si�E'rY "� Certified Tester
Firm Address ' � vuJ v ` f Cent Tester No.,-419M 0 4 W y Date d =�
Gauge # L
Date last accuracy tested
t .
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy