2013_0416CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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
C Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
/ ,, �j 1 LZ /,//V-s Size
Located At
The above is certified to be true.
TUM BREAKER
Check Valve
oSid
Leaked ❑
oSid
Firm Name Certified Tester =/ `
Firm Address
?f ► ��'!? ^� Cert. Tester No.' -Lr /r) �9 Date
Gauge #
r
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V ACl
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
oSid
RP -_psid
Leaked ❑
Did not Open o
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
oSid
RP sid
The above is certified to be true.
TUM BREAKER
Check Valve
oSid
Leaked ❑
oSid
Firm Name Certified Tester =/ `
Firm Address
?f ► ��'!? ^� Cert. Tester No.' -Lr /r) �9 Date
Gauge #
r
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy