2013_1009CHECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: O 1
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.
c
n
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
EE c,
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size
Located At
The above is certified to be true.
Firm Name ;1 A Certified Testa
Firm Address - --7�` Cert. Testa No. `z ' -? Date
Gauge #
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
osid
Tight ❑
Leaked ❑
osid
osid
RP- __psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name ;1 A Certified Testa
Firm Address - --7�` Cert. Testa No. `z ' -? Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy