2013_0517CHECK ONE: " X
IRRIGATION DOMESTIC FIRELINE
BACKFLOW 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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer t
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
c Atmosphere Vacuum Breaker
Size
Located At � �l
UUM BREAKER
Check Valve
osid
Leaked ❑
osid
The above is certified to be true /
Firm Name t`' �� Certified Testa
T t t
Firm Address �-- Cert Testa No. �- j Date
Gauge #
W
Date last accuracy tested
r
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
Tight ❑
Leaked ❑
nsid
osid
PIP - psid
Leaked ❑
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
psid
osid
RP sid
UUM BREAKER
Check Valve
osid
Leaked ❑
osid
The above is certified to be true /
Firm Name t`' �� Certified Testa
T t t
Firm Address �-- Cert Testa No. �- j Date
Gauge #
W
Date last accuracy tested
r
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy