2013_0607CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable par=eters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number �:�, 9f
The above is certified to be true.
1 1 �I
Firm Name Hr
Firm Address,�`!`�
Gauge #
Date last accuracy tested
Certified Tester
Ccrt. 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
Closed Tight ❑
Opened at
Opened at
osid
FOSS
Tight ❑
Leaked ❑
psid
osid
r / ° !
RP -_psid
Leaked ❑
Did not Open C)
Leaked C3
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
1 1 �I
Firm Name Hr
Firm Address,�`!`�
Gauge #
Date last accuracy tested
Certified Tester
Ccrt. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy