2013_1226CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: "3
The bacltilow 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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
! 4T
Size
Located At
The above is certified to be true.
Firm Name 4
Firm Address �� !( C t rA A Y c P#
OLC
Gauge #
Date last accuracy tested
f �
Certified Testa
Cert. Testa No. 1 ' ► ? -'T o lt: Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
RP• A Sid
Closed Tight ❑
Leaked ❑
Opened at
nsid
Opened at
nSid
nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
nSid
nSid
RP sid
The above is certified to be true.
Firm Name 4
Firm Address �� !( C t rA A Y c P#
OLC
Gauge #
Date last accuracy tested
f �
Certified Testa
Cert. Testa No. 1 ' ► ? -'T o lt: Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy