2012_0608 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The back flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is ccrtified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle 1: Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer t 1 ' i ` Y1 Size C_
Model Number Located At i.t i t tl Y
Serial Number
The above is certified to be true.
Firm Name Certified Testa
Firm Address
Gauge #
Cat. Testa No. Date
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
Mid
j I , q _ 1,�
7 —'
Tight ❑
RP -_pSid
Leaked ❑
Leaked C3
Sid
oSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name Certified Testa
Firm Address
Gauge #
Cat. Testa No. Date
Date Last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy