2013_0614 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW 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 certified to be operating within acceptable parameters.
Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
�1
Firm Name / �c`� �' �°)� Certified Tester y'�a �c
Firm Address
l�C' .13 X 7 j ,7 L ,7� ✓19. "Cat Tester No. %' ��1���., iii' Date
Gauge # (" G C' 9 / T f I`
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
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
RP- _psid
Closed Tight C
Leaked o
Opened at
osid
Opened at
osid
osid
Leaked 0
Did not Open 0
Leaked 0
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
opened at
Opened at
_psid
Repair
Tight o
psid
osid
RP sid
The above is certified to be true.
�1
Firm Name / �c`� �' �°)� Certified Tester y'�a �c
Firm Address
l�C' .13 X 7 j ,7 L ,7� ✓19. "Cat Tester No. %' ��1���., iii' Date
Gauge # (" G C' 9 / T f I`
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy