2013_1127 (2)CHECK ONE:
IRRIGATION__
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �1411 ..=:ZL,- -
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.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer % Size
Model Number k" - Located At
Serial Number
The above is certified to be true.
Firm Name Z, Certified Tester
Firm Address / -�- ✓ %� §, , Cert. Testa No. 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
f Air Inlet
Check Valve
Initial Test
DC-Closed
Closed Tight ❑
Opened at
Opened at
Dsid
Tight ❑
Leaked ❑
psid
nsid
RP -, Dsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
Dsid
RP sid
The above is certified to be true.
Firm Name Z, Certified Tester
Firm Address / -�- ✓ %� §, , Cert. Testa No. Date
Gauge #
Date last accuracy tested %
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy