2013_0926CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �/S� r All
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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number 5
Serial Number
Size
J.
Located At �4
The above is certified to be true.
f
Firm Name i.. Certified Tester y
1 ✓
Firm Address r�,,l WOW_ �°� '!'`�` � �i Cert. Tests No. Date
Gauge #
"a
Date Last accuracy tested
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
psid
Tight ❑
Leaked ❑
nSid
pSid
fit„ «Pty
RP- Sid
Lea;ed ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true.
f
Firm Name i.. Certified Tester y
1 ✓
Firm Address r�,,l WOW_ �°� '!'`�` � �i Cert. Tests No. Date
Gauge #
"a
Date Last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy