2013_0814CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: / / % /� P e a' T
The baclflow 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 ❑ Atmosphere Vacuum Breaker
Manufacturer a/ Size
Model Number
Serial Number
o Z
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge # ' / 6 /
Date last accuracy tested
Certified Tester
Cent Tester No. �'� z o Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check: � . G
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
vsid
osid
RP -_psid
Leaked C
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # ' / 6 /
Date last accuracy tested
Certified Tester
Cent Tester No. �'� z o Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy