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CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKTLOW 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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer / n S Size -L�) C
Model Number Located At�
Serial Number 1'7 zJQy,--).;
The above is certified to be true.
0 ,- r--. ..-, , n.
Firm Name Certified Tester
Firm Address �'S fj °� Fr `4'' g, f> t" Cert. Tester No. Date
Gauge # ry
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
nSid
ff
Tight ❑
Leaked ❑
nsid
nSid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
0 ,- r--. ..-, , n.
Firm Name Certified Tester
Firm Address �'S fj °� Fr `4'' g, f> t" Cert. Tester No. Date
Gauge # ry
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy