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CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
11 __ 3-
The baclflow prevention ass , W de Wbelow has been tested
regulations and is certified to be operating within acceptable parameters.
C
❑
Manufacturer
Reduced Pressure Principle
Double Check Valve
Model Number 00-7 YYl _.
Serial Number
TYPE OF ASSEMBLY
as required by TNRCC
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
�CZ
Located At
:JUM BREAKER
Check Valve
oSid
Leaked ❑
nSid
The above is certified to be true.
Firm Name ti. Certified ?esta
Firm A P h �' + Cat. Testa No. aq Date -
..►._ A4
Gauge #
Date last accuracy tested a ' — /
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 ❑
osid
nSid
RP- e 2-paid
Leaked ❑
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
osid
oSid
RP sid
:JUM BREAKER
Check Valve
oSid
Leaked ❑
nSid
The above is certified to be true.
Firm Name ti. Certified ?esta
Firm A P h �' + Cat. Testa No. aq Date -
..►._ A4
Gauge #
Date last accuracy tested a ' — /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy